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Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION 201 E.Washington Ave. <br /> *6onsin In accord with ILHR 83 05,Wis.Adm.Code P.O.Box 7969 <br /> Department of Commerce Madison,WI 53707-7969 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less Count <br /> than 8 vi x 11 inches in size. tel <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> 3�3Y7 <br /> The information you provide maybe used by other government agency programs E]Check it revision to pre s application <br /> (Privacy Law,s. 15.04(1)(m)]. <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Name Property Location <br /> G e d f < 1/4 1/4,S T V6 ,N, R/5--E(or W� <br /> Property Owner's Mailing Addre€c / / Lot Number Block Number <br /> Cvo/N Tom ��l a G) <br /> City,state / / Zip Code Phone Number Subdivision Name o b r <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned 0 City Nearest Road <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms & own of AC C �✓ #�a! P Sf, <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) 8G <br /> 1 ❑ Apartment/Condo O/o` '7-9 --7 <br /> 7a T Z <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. E] Replacement 3. E] Replacement of 4. E] Reconnection of 5. E] Repair of an <br /> System System Only Existing 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 /> 1110 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.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) 9 - 1V Elevation <br /> Feet %�-7Feet <br /> TANK Capact <br /> VII. INFORMATION in allo s Total #Of Manufacturer's Name Prefab. Con_ Steel Fiber- Plastic Exper <br /> New Existing Gallons Tanks concrete strutted glass App <br /> Tanks Tanks <br /> Septic Tank or Holding Tank ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ 1 ❑ ❑ <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) Plumber's Signature:( Stamps) MP/MPRSW No.: Business Phone Number: <br /> /oh <br /> Plumber's Ag(d (Street,City,State,Zip Code): i <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing tSignatur (No tamps) <br /> ar F <br /> Surch ) <br /> Ph"proved F1 Owner Given Initial <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASON FOR DISAPPROVAL: <br /> SBD-6398(FIA 1196) DISTRIBUTION: Original to County,One copy To: Safety 6 Buildings Division,Owner,Plumber <br />