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Safety and Buildings <br /> Visconsin SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> P O Box 7302 <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 County '�^�7 <br /> than 8 v2 x 11 inches in size. /'/v �� / <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> Personal information you provide may be used for secondary purposes ❑Check it r siktl;ilz plication <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION <br /> Property Ow}erName Property Location <br /> e ¢/' 0 1!4 1/4,5 ( T .7 ,N,R ? YE(or)(iR), <br /> Property Owner's Mailing dress L Lot Number Block Number G <br /> 7 J- i <br /> City,State Zip Code Phone Number Subdivision Name o CSM Number <br /> co .J s - �d <br /> PE F BUILDING: (check one) ❑ State OwnedIty Nearest Road <br /> ❑ village <br /> Public 1 or 2 Family Dwelling-No.of bedrooms own OF Q G <br /> 111. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s)q <br /> 1 ❑ Apartment/Condo OC) / �SO ~ OZ ^ 0d <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. 111 New 2. `Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5_ ❑ Repair of an <br /> S�rstem _ _ System Tank Only __ __ Existing5ystem _______ <br /> __ 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 ¢,,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 Pe76a7j 2. Absorp.Area 13. Absorp.Area 4. Loading Rate S. Perc. Rate 6. System Elev. 7. Final Grade <br /> O Requir d(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> 0 Feet 7,,& Feet <br /> VII. TANK Capacity , Site <br /> in gallons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- plastic Exper <br /> INFORMATION New Existing Gallons Tanks Concrete strutted glass App. <br /> Tanks Tanks Odd ❑ El 1:1 1:1 11 <br /> Septic Tank or Holding Tank <br /> Lift Pump Tank/Siphon Chamber D ❑ E 11111 ❑ <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:(No Stamps MPlMPRSW No.: Business Phone Number: <br /> W,A �a �71No 71 .�YY ?-28� <br /> Plumber's Address(streeii�City,State,Zip Code): <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanit ry Permit Fee Includes Groundwater ate IssuedIssuing Age t igna ure N Stamps) <br /> Approved Sur arge Fee) r ^ <br /> pp []Owner Given Initial ! <br /> Adverse Determination <br /> 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 />