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Safety and Bull dingsgs lv <br /> ,- - SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> 1�scons►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 County <br /> than 81/2 x 11 inches in size. .I wul .1-7� aY� <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 ❑Cneck it ior(ro viusappll application <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number (� <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF MATION <br /> Property Owner Name Property Location <br /> B4/I/ TANNE/Z 1/4 'yo1/4,S '33 T //c) ,N, R /y` 4or)W r1�171 <br /> Property Owner's Mailing Address Lot Number Block Number <br /> C rN tq l0 <br /> City,StateZipCode Phone Number Subdivision Name or CSM Number <br /> r1,� <br /> II. TYPE OF BUILDING: (check one) ❑ State Ownedity Nearest Road 17.3(p A <br /> ❑ Village C�77— <br /> Public or 2 FamilyDwelling-No.of bedrooms _ wn OF CrR 111' <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) J /, <br /> 1 ❑ Apartment/Condo Dag �` ��,� — `� <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 S. ❑ Repair of an <br /> --System ---_ System --_---_-_- Tank Only _ Existing System ___ ___ Existing System <br /> ❑ A Sanitary Permit was previously issued. Permit Number Date Issued <br /> 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 eepage 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/day/sq.ft.) (Min./inch) Elevation <br /> 5U 9�s- 9 eFeet Feet <br /> Capp act <br /> VII. INFORMATION in allons Total #of Manufacturer's Name Prefab. Site Con- steel Fiber- plastic Exper. <br /> New Existin Gallons Tanks concrete structed glass App. <br /> Tanks Tanks ray <br /> Septic Tank or Holding Tank /QGII (� ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ <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) Plu ber'sSWat e:(No amps) WP/MPRSW No.: Business Phone Number: <br /> d <br /> Plumber's Address(Street,City,State,Zip Code): <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> y���,_ ❑Disapproved Sa itary Permit Fee (Includes Groundwater ate ssue Issuing A e t Signa ur N a ps) <br /> Ol�AFI roved j � �rcharg2 Fee) l <br /> T p ❑Owner Given Initial / //% p <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 Is Buildings Division,Owner,Plumber <br />