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Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION U 201 W.Washington Avenue <br /> `0'CQnsin In accord with ILHR 83.05,Wis.Adm.Code P 0 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 Count <br /> than 8 1/2 x 11 inches in size. <br /> • See reverse side for instructions for completing this application State Sanitary Perm3it Number( <br /> Personal information you provide may be used for secondary purposes E]Chec�revision o previous application 0 <br /> (Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number ) <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION I <br /> Prop e y Owner Name Ptoperty Location [.� <br /> 0 Aj C_ CS/b/ N3/4IUU) 1/4,S 3 T ! o ,N, R& E(or <br /> Property Owner's Mailing Addre s Lot Number Block Number <br /> s s S ,^/ 0.4 Ks c T <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> II. P BUILDING: (check one) ❑ State Owned ❑ Icy Nearest Road <br /> ❑ Village / <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms Town OF 0,4k 111- cA hal So's <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo t�pa o' 7�13 6 6 OU -40ft <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 /> SystemSystem Tank Only ___ __ Existing System____ ___ Existln�5rstem <br /> B) A Sanitary Permit was previously issued. Permit Number ' Date Issued <br /> V. TYP 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 Weepage Trench 22❑In-Ground Pressure ✓f� 2❑Pit Privy <br /> 13 E]Seepage Pit w2- �p �'� 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 /> p a -7 3.7 5"- ap ! Feet 40 f7 Feet <br /> VII. TANK Capacity Site <br /> in gallons Total #of Manufacturers Name prefab. Con_ Steel Fiber- plastic App.INFORMATION Gallons Tanks concrete glass App.p. <br /> New Existin strutted <br /> Ta <br /> nks Tanks <br /> Septic Tank or Holding Tank « G 1:1 El ❑ 1:1Lift Pump Tank/Siphon Chamber 1:1 El El [3 El <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) �i / / Plumber's Signature:(N Stamps) MP/MPRSW No.: Business Phone Number: <br /> Plumber's Address(Street,City,State,Zip Code): <br /> ,do <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (Includes Groundwater ate ssue Issuin ent Signat e o Stamps) <br /> Surcharge Fee) <br /> C�proved ❑Owner Given Initial 15-, ���J��S <br /> 'p Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(8.11/97) DISTRIBUTION: Original to County.One copy To: Safety&Buildings Division,Owner,Plumber <br />