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Safety and�ul nn Divi9ion <br /> ,•►$CODS%11 <br /> SANITARY PERMIT APPLICATION 2 O Box ashiington Avenue <br /> 302 <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 Cy 4� <br /> than 81/2 x 11 inches in size. I. /1 e <br /> • See reverse side for instructions for completing this application State Sanitary Permit <br /> rNumber <br /> Personal information you provide may be used for secondary purposes ❑Check it revision prev- application <br /> 00q Y, <br /> (Privacy Law,s. 15.04(1)(m)]. <br /> State Plan I.D.Number <br /> 1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION o��toS� <br /> Pro erty0 erName �P opert Location <br /> �Q eiKe— 21k-eK ^jG1/4 61/4,5 31 T ,N, Rj W <br /> Property Owner's Mailing Ad ressLot Number Block Number <br /> 0 o t /tt� <br /> Ci ,State , Zip Cpde Phone Number Subdivision Name or CSM Number <br /> T: yy <br /> II. F DING: (check one) ❑ State Owned Oct r Nearest Road <br /> 171 Public 1 or 2 FamilyDwelling-No.of bedrooms � Town of d <br /> FE PAS <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) ��11 <br /> 1 ❑ ,3 Apartment/Condo 0 " S3 — v M <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 /> ------System --------System --------- _- Tank Only ------------- Existing System _- _ Existing System <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 21XMound 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 /> -7 5O etred(sq-ft.)l Proposed(sq.ft.) (Gals/day/sq.ft. (Min/inch) ElevationO <br /> Z Z.. Feet Feet <br /> aclt <br /> VII. TANK in Ca g gallons #of Prefab. Site Fiber- Ex er. <br /> INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel Plastic p <br /> New Existin strutted glass App. <br /> Tanks Tank <br /> epticTan or Holding Tank 1 11-7 I wr- ❑ ❑ ❑ ❑ El <br /> ump Ta /Siphon Chamber ❑ El El EJ 13 <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibill y for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name: Pri t) Plu is Signature:( Stamps) MP/MPRSW No.: sin ss Phone Number: <br /> elS �e� r 2 Wit' <br /> Plumbe 'SAd ress(Stre t,Cit State,Zyr <br /> de): <br /> �� s i <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved nitary Permit Fee (Includes Groundwater ate IssuedIssuing Ag t Sign tur tamps) <br /> &Approved El Owner Given Initial j'�, Surcharge Fee) <br /> Adverse Determination rov <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.4/99) DISTRIBUTION Original to County,One copy To: safety 8 Buildings Division,Owner,Plumber <br />