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Asconsin <br /> Safety end/Buildings on <br /> D isi SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> P O Box 7302 <br /> Department of Commerce In accord with Comm 83.05,Wis.Adm.Code Madison,WI 53707-7302 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less Count <br /> than 8112 x 11 inches in size. C a3� <br /> • See reverse side for instructions for completing this application Statllanitary_reronitt N�tUmbgr O <br /> Personal information you provide may be used for secondary purposes ❑Check it revision to previous application <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Numbr / <br /> I. APPLICATION INFORMATION- PLEASE PRINT ALL INF RMATI N <br /> Property Owner Name Property Location <br /> G E-1/4 i4/c0 1/4,S 4 T 3�,N, R /YE(or)oj <br /> Property Owner's Mail in dress Lot Number Block Number <br /> Cit , tate Zip Co a I Phone Number Subdivision Name or CSM Number <br /> W S I(;4'5-) 4°6 S 741 t3 r 2�0 J <br /> II. TYPE OF B ILDI : (check one) ❑ State OwnedItyy Ne r st Road <br /> JR <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms Vowao OF 7b <br /> III. B LDING USE: (If building type is public,check all that apply) Parcel Tax <br /> xNNumber(s) <br /> E] V <br /> 1 Apartment/Condo 00 �l J <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 0 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 online B, if applicable) <br /> A) 1. New 2. Replacement 3. Replacementof 4. C] Reconnection of 5. C] Repair of an <br /> ____ _ tem __-_ __System ------------- Tank Only_____________ Existing System----------Existing System <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 /> 121E�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.) Propos2d ft.) (Gals/day/sq.ft.) (Min./inch) 2 / Elevation <br /> -3410 Pf ZS sZ t S �� Feet rr7 'Feet <br /> VII. TANK Capacity <br /> INFORMATION in gallons Total #of Manufacturer's Name Prefab. Site plastic Fxper <br /> New Existing Gallons Tanks Concrete strutted Steel glass App_ <br /> Tanks Tanks <br /> Septic Tank or Holding Tank ❑ El Q I El ❑ <br /> Lift Pump Tank/Siphon Chamberl I Q ' IEl Ej ❑ I ❑ N <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:(No Stamps) MP No.: Business Phone Number: <br /> Ze. <br /> C L�Zc{tet' <br /> Plumber's Address Street,City,State,Zip Code): <br /> oto C� <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sa ar Permit Fee (Includes Groundwater ate IssuedIssuing Agent ignatur (/00 No St s <br /> �A roved }r �u�argefee) y/� <br /> PP El Given Initial 6R J^ �4// <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.4/99) DISTRIBUTION: Original to County.One copy To: Safety a Buildings Division,Owner,Plumber <br />