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Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION 201 E.Washington Ave. <br /> `Asconsin In accord with[LHR 83 05,Wis.Adm.Code P.O.Box 7969 <br /> Department of Commerce Madison,WI 53707-79699 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less Countyds <br /> than 8 112 x 11 inches in size. „u� <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number pyo <br /> The information you provide may be used by other government agency programs ElChec�re:o to p�Js application <br /> [Privacy Law,s. 15.04(1)(m)]. LIJ <br /> State Plan I.D.Number Y <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION <br /> Property Owner Name �L Property Location �4c` <br /> ,1-ti . /Acle 1/4 1/4,So2 Y T ,N, R /7 E(or) W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> /Ck0V^Z s-1 17 1 — <br /> City,State / Zip Code Phone Number Su69iriaien Name or CSM Number <br /> o c.1 i /Owl r 5//S' �6-1 V/Y //.0_/"1r <br /> II. TYPE BUILDING: (check one) ❑ State Owned 0 LityNearest Road <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms - Sa Sa Town OF Cl/U�on� <br /> III. BUILDING USE: (if building type is public,check all that apply) Parcel Tax Number(s) �f / 7 <br /> 1 E] Apartment/Condo a 3� / p l Jd <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. F25,New 2. ❑ Replacement 3_ ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> System System Tank Only Existing System Existing System <br /> ----------------------------------------------------------------------------------------------- <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 /> 11Seepage Bed 21 E]Mound 30 E]Specify Type 41 ❑Holding Tank <br /> 12 R 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 /> O Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) g Elevation <br /> y `1 y .07 J / 6 Feet 9� y Feet <br /> Capacity <br /> VII INFORMATION in gallons Total #of Manufacturer's Name Prefab. Site Con- steel Fiber- Plastic Exper <br /> New Existin Gallons Tanks concrete strutted glass App. <br /> Tanks Tanks p� <br /> Septic Tank or Holding Tank 'VOd ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ I ❑ ❑ I ❑ I ❑ ❑ <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) <br /> lans.Plumber'sName:(Print) Plumber's Signature.(No Stamps) MP/MPRSWNo.: Business Phone Number: <br /> /�J,¢c) <br /> Plumber's Ac dress(Street,City,State,Zip Code): <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> E]Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issu g gent Si n ture(Nostamps) <br /> A I Approved E]Owner Given Initial .< /� Surcharge feel 13_l?_??1 <br /> Adverse Determination `I' ( (J <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBU-6398(R.11/96) DISTRIBUTION: Original to County,One copy To: Safety 8 Buildings Division,Owner,plumber <br />