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Safety and Buildings Division / <br /> `��sconsin 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 <br /> than 8 1/2 x 11 inches in size. <br /> • See reverse side for instructions for completing this application St a sanitar (Peeerrmitiitt NNumbber. <br /> Personal information you provide may be used for secondary purposes E]Check i( M f co previous application <br /> IPrivacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> I. APPLICATION INFORMATION- PLEASE PRINT ALL INF RMATION <br /> Propert Owner Name P pert Location <br /> 1 <br /> 4 tea,S ?$ T40 N, R 16 E(or) 1/ <br /> Property O ner's Mailing Address Lot Number Block Number <br /> 25 - G <br /> City State Zi Code Phone Numberr <br /> l• ( I ) 2 AC>w <br /> GW Na II. TYPE OF BUILDING: (check one) ❑ State Owned 0 Lity Nearest Road <br /> Village ��� K�� �7� <br /> Public 1 or 2 FamilyDwelling- No.of bedrooms 3 Town OF AKAW— - P49 <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 0 401C1 ❑ Apartment/Condo T3v2 <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.jg Replacement g_ ❑ Replacement of 4_ ❑ Reconnection of 5. ❑ Repair of an <br /> System ____- __System _ Tank Only _ Existing _yst.. Ex ....sting.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 /> 1 1 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.Area 3. Absorp.Area 4. Loading Rateq�" <br /> . Perc. Rate 6. System Elev. 7. Final Grade <br /> ,�(r� Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft. Min./inch) nn Elevation <br /> "WD S&2; s(p5 - S _tq .1 Feet (o.$ Feet <br /> VII. TANK Capacity Site <br /> r. <br /> INFORMATION in gallons Gallons Tanks Manufacturer's Name Concrete con- steel glass Plastic App. <br /> New Existingstructed <br /> T nks Tank <br /> Septic Tank or Holding Tank ® ❑ ❑ ❑ 11 <br /> Lift Pump Tank/Siphon Chamber El 0 1:1 11 1 ❑ <br /> Vlll. 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 mps) MP/MPRSW No.: Business Phone Number: <br /> c+F�QD f{cPwr�5 ms.µ,( 225$51 I <br /> PI mber's Address(Street,City,State,Zip Code): <br /> 2-17100 w LJ'E�sr 2 1.�1/. f+491-3 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> 11 Disapproved sanitar ermit Fel (Includes Groundwater ate ssue Issuing A n ignatu ( ) <br /> surce vee) - <br /> pproved E]Owner Given Initial <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REAS5NS FOR DISAPPROVAL: <br /> SBD-6398(R.4/99) DISTRIBUTION: Original to County.One copy To: Safety&Buildings Division.Owner,Plumber <br />