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F - <br /> Safety and Buildings Divis n <br /> Visconsin SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> In accord with(LHR 83.05,Wis.Adm.Code P O Box 7302 <br /> Department of Commerce - Madison,WI 53707-7302 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less Count / <br /> than 8 1/2 x 11 inches in size. u N c�332 <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> Personal information you provide may be used for seconds 3 �us7 <br /> y p y secondary pUrpOSBS ❑Check if revision l0 previous appion <br /> (Privacy Law,s. 15.04(1)(m)]. (1 . <br /> State Plan I.D.Number yJ <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATI N I1�1b <br /> Pr ope yOwner Name P cpertocation v'J <br /> u S <br /> 4/110 e. / (9, 1/4 1/4,5„? T 5/(, ,N, R/ E(or W <br /> Propertypyvner''Maili ss p Lot Number Block Number <br /> ff��1l <br /> City,Sta a Zip Code Phone Number 5ame or CSM Number <br /> II. TYPE OF B ILDIN : (check one) ❑ State Owned 0 CityNearest Road <br /> Public r 2 Famil Dwelling-No.of bedrooms R Vilvag OF�AIK(/t� /�/ N/ So/J <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo 0A 0 + / 3 0 3 70io <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. Ck New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> ____System -------- -------------_ TankOnly--___ _____ - Existing -________E----c-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 D(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.Area3. Absorp.Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 17. Final Grade <br /> RyuRe uired (sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Ele ation <br /> Ys� Y3 6 y r 9`/� Feeti;?,, 6 Feet <br /> TANK Capacrt <br /> VII. INFORMATION in allons Total #of Manufacturer's Name Prefab. Con Steel Fiber- Plastic Exper. <br /> New Existin Gallons Tanks Concrete strutted glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding TankEl El F1 1:1 El�,,,l� S /9 <br /> Lift Pump Tank/Siphon Chamber (C6 4M ❑ ❑ ❑ ❑ ❑ ❑ <br /> VI11. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans- <br /> PI b ir's Na e: <br /> lans.Plumbir'sNa` e:(Print / Plumber's Signature:(No tamps) MP/MPRSW No.: Business Phone Number: <br /> �K�J/2d`�? <br /> Plumber's Address(Street,City,State,Zip Code): 9_ <br /> AJ C.✓.>T' Z <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit F (includes Groundwater rev_/5'4� <br /> te IssuedIssuing Agent Si ature o S <br /> �A roved Surcharge Fee) <br /> , pp ❑Owner Given Initial /75 _ <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.11197) DISTRIBUTION: Original to County.One copy To: Safety&Buildings Division,Owner,Plumber <br />