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Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> r grrsin P o Box 7 I <br /> Departmeh lof Cbmiterce 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=Number <br /> 9than 8 yrx 11 inchesinsize. e4 �3 "• See reverse side for instructions for completing thisON MPUTER/SCANN s1) s7 c2 QPersonal information you provide may be used for secondary purposes ❑Checous application[Privacy Law,s. 15.04(1)(m)]. State P , 9 q 8 <br /> 1. APPLICATION INFORMATION- PLEASE PRINT ALL IN RMATION <br /> Pro ertyOwn NameProperty Location <br /> W1/4 u) 1/4,5 T� N,R16E(or) <br /> Property Owner's Mailing Addrez Lot Number Block Number <br /> =S�tate <br /> ��6 Z Phone Nu r Subdivision Name or CSM Number <br /> )BUILDING: (check one) ❑ State Owned !ty Nearest Road 5 <br /> ❑ Village �-� <br /> Public F1 1 or 2 Family Dwelling-No.of bedrooms 51l..Town of w <br /> 111. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo 1O/ <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 X 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 gNew 2. ❑ Replacement 3_ E] Replacementof 4. E] Reconnection of 5. [3 Repair of an <br /> stem Sm Only ___ Existing System _ _ __ System <br /> Existing <br /> -------ytem ------ <br /> __ __ ___ _ __ ___ <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❑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. Pert. Rate 6. System Elev. 7. Final Grade <br /> Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> S <br /> /S <br /> S—D 6) -- i- Feet DO• Feet <br /> VII. TANK Capac t Site <br /> in gallons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- plastic Exper <br /> INFORMATION New Existin Gallons Tanks Concrete strutted glass App. <br /> T nks Tanks <br /> ieptic Tank or Holding Tank N:7: <br /> 0ift Pump Tank/Siphon Chamber 1:1 <br /> /III. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's <br /> /Name:(P nt) Plumber's Sire: oStamps) MP/MPRSWNo.: Business Phone Number: <br /> Plumber's Address(street,City,state,Vip Code): <br /> .!�OrY ! !i'^eN 7� <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disa fOved San ry Permit Fee B"ciudesGroundwater ate ssue Issuing A Signa re N ps) <br /> pp Surcharge Fee) <br /> 11"proved []Owner Given Initial 906, 60 <br /> 'V Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> DISTRIBUTION: Original to County.One copy To: Safety&Buildina� ; <br />