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Safety an uildings Division <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> fisilI:ionsin In accord with ILHR 83.05,Wis.Adm Code P O Box 7302 <br /> Department bf Commerce Madison,WI 53707-7302 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County - <br /> than 8112 x 11 inches in size. 6!otvh e 7v' ' 3g <br /> • See reverse side for instructions for completing this application State Sanitaa Permit Nu bei ,B <br /> Personal information you provide may be used for secondary purposes ❑Check if revisionJt`o`�rreeviouG/sjapp1plicaiion <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number r ft <br /> 1. APPLI ATI NINF RMATION- PLEASE PRINT ALL INF RMATI N IV <br /> PropertX Owner Nam Property Location ZZ�� <br /> ✓o 4 !4✓>< NEt/a/V w 114,S �9 T 7I N, R /6 E(or)® <br /> Propert Owner's Mailing ddress Lot Number Block Number <br /> 4lYJ v✓)rnne ofk GN• <br /> City State Zgi Code Phone Number Subdivision Name or CSM Number <br /> 11! ma <br /> Ill. TYPE OF BUILDING: (check one) ❑ State Owned [3 State Nearest Road <br /> Villae <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms M Town OF Sw1 SS lfw77 <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo d 3�, <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. ❑ Replacement 3, ❑ Replacement of 4. ❑ Reconnection of 5_ ❑ Repair of an <br /> --__System -___---_System ------------- Tank Only-____--_-_---- Existing System -__--_-_ Exlsttnc�SLrstem <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 /> 11 ❑Seepage Bed 21 ❑Mound 30❑Specify Type 41 ❑Holding Tank <br /> 12N Seepage Trench 22❑In-Ground Pressure 42❑Pit Privy <br /> 13❑Seepage Pit 43❑Vault Privy <br /> 14❑System-In-Fill <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 /> 3�© Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> 7S"0 -7,SSo 9 y I Feet levet 6 Feet <br /> Cap Site <br /> VII. INFORMATION in gallons Total #of Manufacturer's Name Prefab. Con- steel Fiber- Plastic Exper. <br /> New Existin Gallons Tanks Concrete structed glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank 8th c?00 I .S&a &v ® ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ 1 ❑ ❑ <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: o PbTps) MP/MPRSW No.: Bu mess Phone Number: <br /> ,QD S 2Z- SSI S-$ - 463 <br /> PI ber's Address(Street,City, tate,Zip Code): <br /> o W 3; <br /> IX. COUNTY7DEPARTMFNT USE ONLY <br /> E]Disapprove( Sani yPermitFee (includes Groundwater ate IssuedIssuing Agent Si ature Nosta s) <br /> roved sur argeFee) <br /> pp ❑Owner Given Initial 1 �� <br /> Adverse Determination / <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.11/97) DISTRIBUTION: Original to County,One copy To: Safety 8 Buildings Division,Owner,Plumber <br />