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r� <br /> fir Safety andBui ings Division <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> f isconsin 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 County 3°l0 <br /> than 81/2 x 11 inches in size. u <br /> • See reverse side for instructions for completing this application State Sanitary Permit Nurmlb <br /> Personal information you provide may be used for secondary purposes ElCheck 1 revislnn to previous application <br /> (Privacy Law,s. 15.04(1)(m)]. C <br /> State Plan I jyu er <br /> 1. APPLICATION INFORMATION - PLEASEPRI T ALL INFORMATION <br /> Property wrierame <br /> e Property Location <br /> r/ 1/4 1/4,S3 s—' T Y� ,N, R 6 E(or� <br /> Property Owner's Mailing Ad�s Lot Number �r <br /> ,2_3o �¢u� f3 <br /> City,StateZip Code Phone Number Subdivision Name or CSMumber <br /> TA5<,ee, <br /> II. F BUILDING: (check one) ❑ State Owned [I CNearest Road <br /> ae <br /> Public j or 2 FamilyDwelling-No.of bedrooms r Vown OF <br /> rie- <br /> 111. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> I]GYJ� <br /> 1 ❑ Apartment/Condo 03v2 o <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. Ig New 2. ❑ Replacement 1 ❑ 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 ❑Seepage Bed 21 []Mound 30❑Specify Type 41 ❑Holding Tank <br /> 12 0-Seepage Trench 22❑In-Ground Pressure t, 42 El Pit Privy <br /> 13❑Seepage Pit /7'_"n 3❑Vault Privy <br /> 14 El 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 /> Requir q.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> 7r 95! Feet 97 Feet <br /> VII. TANK Capacity <br /> INFORMATION in gallons Total #of Manufacturer's Name Prefab. Site Fiber- Plastic Exper. <br /> New Existin Gallons Tanks Concrete Con- steel glass App. <br /> Tanks Tanks structed <br /> Septic Tank or Holding Tank p ��D 0-, El ❑ 1 11 ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber !320d �OrJ <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/MPRSW No.: Business Phone Number: <br /> Plumber's Address(Street,City,State,Zip Code): <br /> ,Bars' S/ jeSl/'�.J G✓ Sli`�72 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (Includes Groundwater ate slue Issuing Age gnatur N 5 ) <br /> pproved ❑Owner Giveninitial l i�W�argeFee) '/ <br /> 11 j Adverse Determination / -7 (�j�J S�a1 <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.4199) DISTRIBUTION: Original to County,One copy To: Safety&Buildings Division,Owner,PI. Ser <br />