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Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> %6consin P O Box 7302 <br /> Department of Commerce In accord with comm 83.05,Wis.Adm.code Madison,WI 53707-7302 <br /> • Attac, complete plans(to the county copy only)for the system,on paper not less County <br /> than 8 1/2 x 11 inches in size. <br /> • See reverse side for instructions for completing this application State SanitaryPePermmi Nuum�bbeer <br /> 41- <br /> Personal information you provide may be used for secondary purposes El Check if revision[b previou3 apaplication —' <br /> [Privacy Law,s. 15.04(1)(m)]. <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION _� <br /> ProertyOwner ame P pert L ation Air <br /> O� ) s >w 1/4 1/4,S ?J T40 ,N, R I¢ E(or W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 2S 8 7 CO- Ro A <br /> City, tate Zip Code Phone Number Subdivision me or CSM Number <br /> 1�1- 3 (�iS) S- £S <br /> 11. FBUILDING: (check one) ❑ State Owned ❑ City Nearest Road <br /> Public 1 or 2 Famil Dwellin -No.of bedrooms 3 ❑ villTownageOF Co-v, Rp A <br /> III. BUILDING USE: (if buildingtype is public,check allthatapply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo 028 44ZI = <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. E3 Replacement of 4. E3 Reconnection of 5. E] 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 21 []Mound 30❑Specify Type 41 ❑Holding Tank <br /> 12"eepage Trench 22❑In-Ground Pressure 42❑Pit Privy <br /> 1 []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 /> Re red (sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) 4 Elevation <br /> qui <br /> O 7. .S 0 " -15- is Feet 97.2 Feet <br /> Ca act <br /> VII. TANK in gallo s Total #of Prefab. Site Fiber- Exper. <br /> INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App <br /> New TE­ structed <br /> Tanks Tanks <br /> Septic Tank or Holding Tank UV ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber �' ❑ ❑ ❑ 11 1:1 <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:(Pri t) Plumber's Signat r :( Stamps) MP/MPRSW No-: Business Phone Number: <br /> g 4 I 'A5`- - S <br /> PI ber's Address(Street,Cit , tate,Zip Code) <br /> 7 S' W1. S <br /> IX. COUNTY/DEPART ENT USE ONLY <br /> ❑Disapproved $apiIt Permit F e (Includes Groundwater ate ssue Issuing A e Sign re S s) <br /> Oved ,��-1L1�\' /" +rcharge Fee) <br /> ❑Owner Given Initial (/ /� <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.4/99) DISTRIBUTION: Original to County.One copy To: Safety$Buildings Division,Owner,Plumber <br />