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and <br /> Visconsin SANITARY PERMIT APPLICATION 201 Safety <br /> WaBulding <br /> ington Avenue <br /> Department of Commerce In accord with Comm 83.05,Wis.Adm.Code P O Box 7302 <br /> Madison,WI 5370 -7302 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County <br /> than 81/z x 11 inches in size. � �� <br /> • See reverse side for instructions for completing this application Sate Sanitary Permit tuber <br /> Personal information you provide may be used for secondary purposes E][Privacy Law,s. 15.04(1)(m)]. ❑Check i revision to pre ious application <br /> I. APP LI ATI N INFORMATION- PLEASE PRINT ALL INF RMATION State Plan I.D.Number <br /> Property Owner ame ...a <br /> Property Location <br /> S <br /> Property Owner's Mailing Address 1/4 1/4, T 4b ,N, R E(or)1 <br /> Lot Number <br /> Q - ' Block Number <br /> C ty tate Zip Code 14 tZdff4_!2 P ne Number Subdi Sion m Torr C�jVI Number <br /> V• I _ I�J <br /> 11. PEI •DING: (check one) ❑ State Owned ❑ 't Nearest Road ^ <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms Z ❑ vii age J2I k � <br /> Town OF�Jr+-r.7v� <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo 012 47_25 O's Goo <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 <br /> 4 [1Church/School 8 E] Mobile Home Park E] Restaurant/Bar/Dining <br /> 5 El Hotel/Motel 12 E] Service Station/Car Wash <br /> 9 El 13 C] 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. Replacementof <br /> /'S stem ❑ Tank Only 4. ❑ Reconnection of 5. ❑ Repair of System Y ________System __________ __ _ ___ y -- __- __ExlstingSystem Existingi-----ystem <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 <br /> 12[]Seepage Trench ❑ 30 El Specify Type 41 olding Tank <br /> 22❑In-Ground Pressure <br /> 13 42❑Pit Privy <br /> ❑Seepage Pit <br /> 14❑System-In-Fill 43❑Vault Privy <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 /> { Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) I l <br /> Elevation <br /> VII. TANK Capacity Feet Feet <br /> In gallons Total #of <br /> INFORMATION g Gallons Tanks Manufacturer's Name Prefab. con fiber- Plastic Exper <br /> New ExistingConcrete structed Steel glass App- <br /> Septic <br /> nit Tanks <br /> Septic Tank or Holding Tank G� ❑ ❑ ❑ El ElLift Pump Tank/Siphon Chamber ❑ 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 Si nature:(No S ps) MP/MPRSW No.: Business Phone Number: <br /> I nao ZZ�g� <br /> P umber's Address_76(Street, ity,State,Zip Codd/Q�)- <br /> IX. COUNTY/DEPA TMENT USE ONLY �1 <br /> ❑Disapproved SanitaryPermit Fee (Includes Groundwater a sue p ) <br /> Approved Surcharge fee) Issui�Age Signa r S s <br /> ❑Owner Given Initial c I�5 !� �3 <br /> Adverse Determination <br /> X. ONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.4/99) DISTRIBUTION: Original to County,One copy To: Satety a Buildings Division,Owner,Plumber <br />