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&-0? 6P-9?P <br /> Safety and Buildings Division <br /> `vSANITARY PERMIT APPLICATION sconsin 201 E.Washington Ave. <br /> Department of Commerce In accord with ILHR 83.05,Wis-Adm.Code P.O.Box 7969 <br /> Madison,WI 53707.7969 <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. l ll oZ a <br /> • See reverse side for instructions for completing this application Stl3-anitary_Pergnit Number <br /> The information you provide may be used by other government agency programs [:]Check it revisl3nto previous appli ation <br /> IPrivacyLaw,s. 15.04(1)(m)]. State Plan I.D.Number <br /> 1. APPLICATION INFORMATION- PLEASE PRINT ALL INF RMATION <br /> Property Owner Name Property Location <br /> 1/4 j )1/4,S 1d) T ,N, R / E-(erlW <br /> Property Own 's NJcjiling Addres Lot Number Block fV tuber <br /> City Stat Ot7p)\ N Zip ode Phone Number Subdivision Name or CSM Number /� <br /> C. s n )35V-3/ Lv GS <br /> ill. T LDING: (check one) ❑ State Owned Elitr ea estRoad <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms � o o age O, <br /> own OF /u.e.3 <br /> III. BUILDIN USE: (If bu i Idling t ei kal``t apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Con (..)� cl <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 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 CR eepage 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 /> L./ <br /> Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq. ft.) (Min./inch) Elevation <br /> Viilll vs , Feet ,04 et <br /> VII. TANK Capacity <br /> in gallons Total #of Prefab- Site Fiber- Ex er. <br /> INFORMATION Gallons Tanks Manufacturers Name Con- Steel Plastic p <br /> New Existin Concrete strutted 91ass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank ❑ El El 1:1 El <br /> Lift Pump Tank/Siphon Chamber I I Ej El El Ej El El <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plu er's Name:(Print) Plum er's Signature:(No Stamps-Tl P PRSW No.: Business Phone Number: <br /> Plumber'sA dress(Street,City,State,Zi Code): <br /> Pr - LSU <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sa Itafy Permit Fee (includes Groundwater ate IssuedIssuinZntar Stamps) <br /> pproved Surcharge Fee) /� <br /> ❑Owner Given Initial s �0'^,a-Surcharge 1// <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASO 5 FO DISAPPROVAL: <br /> SBD-6398(R.17/96) DISTRIBUTION: Original to County.One copy To: Safety&Buildings Division,Owner,Plumber <br />