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Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> In P O Box 7302 <br /> Department of Commerce In accord with Carat 83'06'�'Adm.COO Madison,WI 53707-7302 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County <br /> than 8 in x 11 inches in size. <br /> • See reverse side for instructions for completing this application State Sanitary Permit �mt_► - <br /> Personal Information you provide may be used for secondary purposes ❑Check it remion to pFwioA motion <br /> [Privacy Law,s. 15.04(1)(m)). State Plan I.D.Number <br /> 1. APPLICATION INFORMATION-PLEASE PRINT ALL INF RMAT <br /> Pro pert Owner Name Propert Ocation <br /> t/4 1/4,S S T ' ,N,R f$ E(o W <br /> Property Owner's Mailing Address Lot Number <br /> Ci ,State Zip a Phone Number Subdivision Name or CSM Number <br /> s' p ,ty Nearest Road <br /> 11L 'TYPE OF BUILDINIG: (check one) [:1 state Owned to village <br /> Public 1 or 2 FamilyDwellin -No.of bedrooms Town OF <br /> III, BUILDING USE: (If building type is public,check all that apply) Parcel Tax Numbers) <br /> 1 ❑ Apartment/Condo <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 Q 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 8,if applicable) <br /> A) 1. ❑ New 2.,Z Replacement 3_ ❑ Replacement of 4. ❑ Reconnection of 5_ ❑ Repair of an <br /> Tank On( Existinc�System Existing System <br /> ------She"-"---------Syfstem------------- y-------------_ _----- <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 /> 11JEfSeepage Bed 21 ❑Mound 30❑Specify Type 41 ❑Holding Tank <br /> 12❑Seepage Trench 22❑In-Ground Pressure 42 Q Pit Privy <br /> 13❑Seepage Pit 43❑Vault Privy <br /> 14❑System-in-Fil I <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 /> �%O Re fired(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Minch) n4.Q Elevation <br /> 2 -1 —! -1 Feet '7.4 Feet <br /> VII. TANK Capacity Site <br /> in gallons Total #of Manufacturer's Name Prefab. Con- Steel fiber Plastic Exper. <br /> INFORMATION New Existin Gallons Tanks Concrete strutted glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank !Q <br /> Lift Pump Tank/Si hon Chamber 10 11 El <br /> VIII. 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:=S ) MMP/MPRSW No.: Business Phone Number: <br /> l 1,5- 46-4151 <br /> Plu ber's Address(Street,City tate,Zip Code): <br /> as- <br /> 1- <br /> IX. CO lr-PARTMENT USE ONLY <br /> ❑Disapproved Sanitar ermFee Ina"d"Ground ws"e` ate IssuedIssuingAen ejNtPS) <br /> ❑Approved Owner Given Initial /it &0urchargefee) <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FORDISAPPROVAL: <br /> 38D$M(1R.4199) OISTR+1IUTION: Original to County.One copy To.Safety 6 Buildings MvWon,Owner,Plumber <br />