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Safety ant)'B'ul ings Dvision <br /> Visc6psin SANITARY PERMIT APPLICATION 201 W.Washington Avenue 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 syster>OMempp1 l ss County a I <br /> than 8112 x 11 inches in size. f UUTT roe <br /> • See reverse side for instructions for completing this application State e(rrmmn NUMDeer <br /> 79 <br /> Personal information you provide may be used for secondary purposes E]Check it rZon to :?- <br /> previous application <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION I <br /> Pro erty Owner NameProperty Location 1 <br /> eVl C>1v1 r SVji/4 �JG1/4,S '1 T tTU ,N, Rta <br /> fSb{er�N <br /> Property Owner's Mailin Address Lot Number Block Number <br /> City,Stat Zip Code Phone Num er Subdivision Name or CSM Number <br /> /, qql Gov 4o'- a -S ub Loi' W <br /> II. TYPE B ILDING: (check one) ❑ State Owned ❑ ityy \\ /�� Nearest Road <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms °Towan OF Jt[C t—J� Irrt <br /> 111. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo v l — — 0.7�_ &CO <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. Cg 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 []Seepage Bed 21 ❑Mound 30❑Specify Type 41 ❑Holding Tank <br /> 12 IRSeepage 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.) Proposed(sq.ft.) (Gals/day/sq.ft.) (MinAnch) / Elevation <br /> *30V `o 6• SFeet Feet <br /> Capact <br /> VII. FORMATION Site <br /> in allons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- plastic Exper. <br /> New Existin Gallons Tanks Concrete structed glass App. <br /> Tanks Tanks <br /> Septic T or Holding Tank ,�} , ltta (�)/ CR E] El 11 1:1 El <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's Name: Print) Plu ber's Signatur :(N Stamps) MP/MPRSW No.: Business Phone Number: <br /> ): <br /> �' <br /> Plumber's Address(Street,City,StateipCodeo <br /> D 6Sr t r SsF <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sani ry Permit Fee (Includes Groundwater ate slue Issuing Age gnature o <br /> A roved charge Fee) <br /> pp ❑Owner Given Initial �s ` < <br /> Adverse Determinati <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-8398(R.4/99) DISTRIBUTION: Original to county.One copy To: Safety a Buildings Division,Owner,Plumber <br />