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cwele <br /> Safety and Buildings Division <br /> 7 <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> Vimonsin P a Box 7302 <br /> In accord with(LHR 83-05,Wis.Adm.Code Madison,WI 53707-7302 <br /> Department of Commerce <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County <br /> than 812 x 11 inches in size. el <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> et <br /> Personal information you provide may be used for secondary purposes ❑ChI vislo o9evio ePlication <br /> (Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> r-� <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL IN MATI N <br /> Property Owner Name /' Property Location <br /> Q U tnJ / 5E 1/4 1/4,5 / 7T Y� •Nr R JS E(orig <br /> G <br /> Property Owner's Maili�Address �-/f�� Lot Number Block Number <br /> rL e0u rT <br /> City,State c Zip Cody Phone Number Subdivision Name or CSM Number <br /> P ILD( (check one) ❑ State Owned ty <br /> 4Neare?st;Road <br /> Public 1 or 2 Famil Dwellin -No.of bedrooms Towan OF W/ T. c.— L �j <br /> III. BUILDING USE: (If buildingtype is public,check all thatapply) Parcel Tax Number(s) <br /> era- s� (-7 03 � <br /> 1 ❑ Apartment/Condo <br /> 2 [:] Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 E] Campground 7 ❑ Merchandise: Sales/Repairs <br /> 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 KNew 2. ❑ Replacement 3. ❑ Replacement of 4. ❑.Reconnection of 5. ❑ Repair of an <br /> System __ _ System _____________ TankOnly______________ Existing System ________ ExlstlnaSystem <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 /> 12❑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 /> Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> oo y ;)— ��isFeet Feet <br /> •JCapacity <br /> VII. TANK in gallons Total #Of Prefab- Site Fiber- Plastic Exper. <br /> INFORMATION g Gallons Tanks Manufacturer s Name Concrete Con- Steel glass App <br /> New U—isting structed <br /> Tanks Tanks n 1 <br /> Septic Tank orHoldingTank 0a 11 El o 0 <br /> Lift Pump Tank/Siphon Chamber ❑ Li ❑ <br /> Vlll. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name:(Prin Plumber's Signature:(No Stamps) MP/MPRSW No: Business Phone Number: <br /> A)/4z:,A-- /,76/, <br /> Plumber's Address(Street,City,Statef,Zip Code): ..5_95_4� 7 2 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> [IDisapproved Sanitary Permit Fee I Groandwafer ate IssuedIss g A ent Sign a(No Stamps) <br /> Disd pp Sure Surcha,arge Fee) <br /> Approved ❑Owner Given Initial <br /> Adverse Determination (J LJ <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> DISTRIBUTION: Original to County,One copy To: Safety B Buildings Division,Owner.Plumber <br /> SBD-6398(R.11197) <br />