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Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> Vliconsin P O Box 7302 <br /> `Department of Commerce In accord with Comm 83.05,Wis.Adm.Code Madison,WI 53707-73 2 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County <br /> than 8 tie x 11 inches in size. &C{?w lep� <br /> • See reverse side for instructions for completing this ap7,c8,ti, State Sanitar Perrjmit Nummbbe/r'`�L b <br /> Personal information you provide may be used for secondary purposes check if roit'io ious application <br /> [Privacy Law,s. 15.04(1)(m)I. � St PState Plan LD.Nu rI. APPLI ATI N INFORMATION- PLEASE PRINT TION <br /> Prope y caner ame Property Location <br /> 1jLcJ1/4,S /V T 7"�/ <br /> O ,N, R/,9Z{°r� <br /> Pro rt' bwner's Mailing ddress Lot Number Q Block Number <br /> MQ r-e �f <br /> City St atr Zip P hone Number SubdivisionDee Name of SSM Nu b r <br /> A (A <br /> II. TYPE OF BUILDING: (check one) ❑ State OwnedV'til�age arest Roa 1 Gr tG <br /> ❑ /� �f <br /> Public JZ 1 or 2 Family Dwelling-No.of bedrooms Town OF 12 <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) Z '^7 <br /> 1 ❑ Apartment/Condo 0 L C;L C Z J v—3v `150 <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. Atf New 2. E] Replacement 3_ (] Replacement of 4_ ❑ Reconnection of 5. E] Repair of an <br /> f-' 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❑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 Rate 5. Perc. Rate 6. System Elev. 7. Final Grade <br /> Requ'red(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) C� r Elevation <br /> 30 o Z Z , ! Feet Feet <br /> TANK Capacct Site <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 /> epticTank rHoldingTank K I 7S7) Dd ❑ ❑ ❑ ❑ 1 ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ ❑ 1 ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsi Ility for installation of the onsite sewage system shown on the attached plans. <br /> PI er'/`Nam (Print) PI mber's Signatur :(N Stamps) MP/MPRSW No.: Business Phone Number: <br /> tV � Y �� 22-S�Z Q <br /> Plum 's Ac1dr9sS(Street, ity,State,Zip Code): 1 r L r <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑DisapprovedSa i ary P rmit Fee (includes�Groundwater ate slue Issuing Age Si a e( S mps) <br /> oved ❑Owner Given Initial v ve Fee) 9r <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 />