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Safety and Buildings Division <br /> `���wwnn SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> +�3+J�•�,� In accord with ILHR 83.05,Wis.Adm.Code P O Box 7302 <br /> Departmentot Commerce Madison,WI 53707-7302 <br /> • AttaPh complete plans(to the county copy only)for the system,on paper not less County (;Z,7]-7 <br /> `��� N <br /> than 81/2 x 11 inches in size. <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> 3)g 5C?3 1 <br /> Personal information you provide may be used for secondary purposes ❑Check it revision to previous application ,1 <br /> (Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> 1. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION 1 414 <br /> Prop Owner Name Property Location <br /> 1/4 1/4,S 5G T 4 J ,N,R jio E(or W <br /> Property Owner's Mailing AAds;ddreLot Number Bleek+Ampbw PS S <br /> VF <br /> Cit S ate Zip ode Phone Number Subdivision Name or CSM Number <br /> Co c of 4�3� ( IS) z <br /> II. B ING: (check one) ❑ State Owned ill c Nearest Road <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms 3 I rowan OF S JSS ltf u2dR CIRLt_E <br /> III. BUILDINGUSE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo 0.32 S33160 DZ RoO <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.,M Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5_ ❑ Repair of an <br /> ____System ________System -___________ TankOnly_ ____________ Existing System _-_______ExlstingSystem <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 M 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.Perc. Rate 6. System Elev. 7. Final Grade <br /> RegLrAed�sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) p Elevation <br /> AW I Z1_T Feet Feet <br /> i <br /> VII. TANK Capacity site <br /> INFORMATION in gallons Gallons Tanks Manufacturer's Name CPrefab <br /> ne este CO" steel g ass Plastic ErxpPr. <br /> New Existin strutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank 0001000 A ❑ ❑ ❑ ❑ El <br /> Lift Pump Tank/Siphon Chamber I 1 0 El El 11 ❑ 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) Plumber's Signature:(NoS ps) MP/MPRSWNo.: Business Phone Number: <br /> Ic op ,� - 22-5851 <br /> Plu ber's Address(Street,City, t te,Zip Co <br /> a <br /> .-es[ 0 <br /> IX. COUNTY/DEPARTM E14T USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (Includes Groundwater ate ssue Issuingg tsigMtuamps) <br /> roved Surcharge Feel <br /> pp ❑Owner Given Initial <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FDISAPPROVAL: <br /> SBD-6398(R.11197) DISTRIBUTION: Original to County.One copy To: Safety&Buildings Division,Owner,Plumber <br />