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jr� U ,^14Safety and Buildings Division <br /> *Lconsin SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> 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 81/2 x 11 inches in size. et <br /> • See reverse side for instructions for completing this application State Sanitary Permit Numbe <br /> � _350 <br /> Personal information you provide may be used for secondary purposes ❑check I revision to previous application <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> I. APPLICATION INFORMATION- PLEASE PRINT ALL INF RMATION <br /> Property Owner Name Property Location1 J <br /> /4 1/4 1/4,5 T N,R&e E(or <br /> Pr perty Own ' Mailing Addr /ss, Lot Number Block Number <br /> City'StateipCode Phone Number Subdivision Name or r <br /> tie sy09 3 <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ City ]NearestRoad <br /> ❑ Village <br /> Public ff 1 or 2 Family Dwelling-No.of bedrooms 14 Town OF .J 5 <br /> III. BUILDING USE: (if building type is public,check all that apply) Parcel Tax Number(s)y <br /> 1 E] Apartment/Condo <br /> s) <br /> D lQ v <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. ogyeplacement 3. ❑ Replacement of 4. ❑ Reconnection of 5_ E] Repair of an <br /> ____ System __ _ ystem -__ ---- Tank Only___ ___ _ Existing System _ _ ___ Existii2gSytstem <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 /> 12Seepage Trench 22 E]In-GroundPressure 11 c 42 E]Pit Privy <br /> 13 <br /> 12P <br /> Seepage Pit / 43❑Vault Privy <br /> 14❑System-In-Fill - /Aiete>i�Jc�e <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/ ay/sq.ft.) (Min./inch) cy Elevation' <br /> Feet �� Feet <br /> Ca aclt <br /> VII. TANK FORMATION in gallons Total #of Manufacturer's Name Prefab. Con Steel Fiber- plastic App- <br /> New Existin Gallons Tanks concrete structed glass App. <br /> Tanks I Tanks <br /> Septic Tank or Holding Tank ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ L ❑ ❑ <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:(Pri ) Plumber's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> Azle- 1 ur5:ia�i�i <br /> Plumber's Address(Street,City,State,Zip Code): �y <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (includes Groundwater ate ssue Issuing entSi natt�ur tamps) <br /> urcharge Fee) p <br /> proved ❑Owner Given Initial /�Q g-/a-j CYr <br /> Adverse Determination / <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.11/97) DISTRIBUTION: Original 10 County.One copy To: Safety a Buildings Division,Owner,Plumber <br />