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' SANITARY PERMIT APPLICATION Safety and Buildings enu <br /> ■ 201 W.Washington Avenue <br /> iiscons�n 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 <br /> than 8 112"z 11 inches in size. coup ¢. <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> Personal information you provide may be used for secondary purposes ❑Check,iH€vf� pplication <br /> [Privacy Law,s. 15.04(1)(m)]. <br /> State PI LD.N tub r <br /> I. APPLICATION INFORMATION- PLEASE PRINT ALL INF RMATION 4/176 <br /> Property Owner Name Property Location <br /> C"rq Ile- G,-.�eiv 1/4 1A,5 ,N, R 7E(o W <br /> Property Ow 's Mailing Address 1 Lot tuber Block Number <br /> eF 1, /Ver �✓ U Dr illJ e " , <br /> City,State ! / Zip <br /> V� Phone;um7 ber Subdivision Name or CSM Number <br /> -li- y�- s3 s <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned o vitae Nearejt Road ?3 <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms Town OF 2 S ©! <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo 4R 4 <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. f9tNevv 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> ---__-y!stem _ System -- Tank Only---_----_-- - Existing System --_ Existln�Syrstem <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 aMound 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//sq.ft.) (Min./inch) 97 Elevation <br /> QQ SU o7j'�L / Feet ,3 Feet <br /> TANK Ca aclt <br /> VII. INFORMATION in gallons Total #of Manufacturer's Name Prefab- Con- steel Site Fiber- plastic Exper <br /> New Existin Gallons Tanks Concrete structed glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank 75-1! ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber i-tQ ❑ ❑ ❑ ❑ <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:(Prin pp Plumber's Signature: NoSta ps) MP/MPRSWNo.: Business Phone Number: <br /> Plu9ber' Address(Street,City,State,Zip Code): <br /> IX4 COUNTY/DEPARTMENT USE ONLY <br /> E]Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing entSigna�Stamps) <br /> Kpproved' I []Owner Given Initial Pcn Surcharge Fee) <br /> Adverse Determination _ ` <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.4199) DISTRIBUTION: Original to County.One copy To: Safety a Buildings Division,Owner,Plumber <br />