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Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> Msclliiilnsin In accord with ILHR 83.05,Wis.Adm_Code P O Box 7302 <br /> Department of Commerce Madison,WI 53707-7302 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County ^ <br /> than 8 112 x 1 1 inches in size. upoigirp( <br /> • See reverse side for instructions for completing this application State Sanitary P rmitCt Number <br /> Personal information you provide may be used for secondary purposes ❑Ch—, 1f rev t�o pre�ous application <br /> (Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> I. APPLICATION INFORMATION- PLEASE PRINT ALL INF MATI IN <br /> / <br /> PropName Property Location <br /> gQgrjg CH 5 2,4- T 40 rNr R /d <br /> E(or& <br /> Property Owners Mailing Address Lot Number / Block Number <br /> do R,0. £ <br /> Cit ,State Zi Code Phone Number Subdivision Name r SM No e <br /> wl 4-1 ( s)r3s- 634 ��if i .a/9 <br /> II. TYPEBUILDING: (check one) ❑ State Owned ❑ City N&mlfst Road <br /> ❑ VII age ^ <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms 3 Town OF-S 66 r t�-r7+ eW. 17- E <br /> Ill. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo UA U^ 7/�4� e�3 6 00 <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining <br /> 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash <br /> 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: specify <br /> IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B,if applicable) <br /> A) 1. ❑ New 2. 14 Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5, ❑ Repair of an <br /> ------SSystem <br /> ystem --------S�rstem ------ Tank Only--------- ---- Existing System -------- Exi---stinQ----- <br /> --------------- <br /> B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued <br /> V. TYPE OF SYSTEM: (Check only one) <br /> Non-Pressurized Distribution Pressurized Distribution Experimental Other <br /> 110 Seepage Bed 21 ❑Mound 30❑Specify Type 41 []Holding Tank <br /> 12❑Seepage Trench 22❑In-Ground Pressure 42❑Pit Privy <br /> 13❑Seepage Pit ' 43❑Vault Privy <br /> 14❑System-In-Fi II <br /> VI. ABSORPTION SYSTEM INFORMATION: <br /> 1.Gallons Per Day 2. Absorp.Area 3. Absorp.Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade <br /> ASO <br /> Required sq.ft.) Proposed(sq.f2) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> ASO !,�'� 9s•� Feet q7.s Feet <br /> Capcit <br /> VII. TANK in allons Total #of Manufacturer's Name Prefab. Con- steel Site Fiber- Exper. <br /> INFORMATION Gallons Tanks Concrete glass Plastic App <br /> New Existin strutted <br /> Tank Tanks <br /> Septic Tank or Holding Tank 1Q00 loon A ❑ El ❑ 0 <br /> ❑ft Pump Tank/Siphon Chamber OO <br /> VI11. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name:(Print) Plumber's Signature:(No St ps) MP/MPRSWNo.: Business Phone Number: <br /> PI tuber's Address(Street,City,State ip Code): <br /> 'L 76a jjjw35 WosrimWt. 3 <br /> IX. COUNTY/DEPARTMENT SE ONLY <br /> E]Disapproved Sanitary Permit Fee (Includes Groundwater ate slue Issuin nt Si a r o Stamps) <br /> A roved ._&urcharge fee) q <br /> pp ❑Owner Given Initial C7SJ , <br /> Adverse Determination U <br /> X. CONDITIONS OF APPROVAL/REASONS FOR ISAPPROVAL: <br /> ;BD-6398(R.11197) DISTRIBUTION: Original to County.One copy To: Safety&Buildings Division,Owner,Plumber <br />