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Safety and Buildings Division <br /> 06consin SANITARY PERMIT APPLICATION 201 E.Washington Ave. <br /> In accord with ILHR 83.05,Wis.Adm.Code P.O.Box 7969 <br /> Department of COmmerf Madison,WI 53707-7969 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less county ��� n <br /> than 8 12 x 11 inches in size. `� <br /> • See reverse side for instructions for completing this application St to Sanitary Permit Number <br /> 4 , <br /> The information you prov a maybe used by other government agency programs E]Check 2113 t previous app rcahon <br /> (Privacy Law,s. 15.04(1)(m)1-�` State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION <br /> Property Owner Name Property Location ' <br /> m1/4 1/4,S 13 T 41 ,N, R lkli E(or W <br /> Property Owner's Mai i Address Lot Numberr <br /> I ST. k.£. L. <br /> City,State Zi Code Phone Number Subdivision Name or CSM Number <br /> MPLS <br /> 11. TYIPL 0 B 1 DING: (check one) ❑ State OwnedE] city Nearest Road <br /> El Public 1 or 2 FamilyDwelling- No.of bedrooms H Towao OF W ISS Qp <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo 6,sz .5:31-S bl <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.X New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> ____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)2 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 /> Required(sq. ft.) Prop sed s Z.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> � 4 "�— 9S•7 Feet Feet <br /> Capcit <br /> VII. TANK in llo s Total #of Prefab. Site Fiber- Exper. <br /> INFORMATION g Gallons Tanks Manufacturers Name Concrete strutted Steel Plastic <br /> New Existin glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank ♦ Q [jEl ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber'sName:(Print Plumbe 's Signatur :(N amps) MP/MPRSW No.: Business Phone Number: <br /> �A� IS- - <br /> PI ber's Ac dress(Street,Cit tate,Zip ode): <br /> 1- 91Sq3 <br /> IX. COUNTY I DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (Includes Groundwater ate IssuedIssuing g t Sign re( a ps) <br /> oved ElOwner Given Initial Surcharge Fee) L/ <br /> Adverse Determination 75 °� 7 <br /> r4 dyw <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.11/86) DISTRIBUTION: Original to County.One copy To: Safety 8 Buildings Division,Owner,Plumber <br />( <br />