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t�X-'i i-� Safety and Buildings Division <br /> Nylirvonsin SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> In accord with ILHR 83.05,Wis.Adm.Code <br /> Department of Commerce P O Box 7302Madison,WI 53707-7302 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County <br /> than 81/2 x 11 inches in size. <br /> • See reverse side for instructions for completing this application i S to Sanitary Permit Number <br /> N <br /> Personal information you provide may be used for secondary purposes fir) 3 Y� SU <br /> (Privacy Law,s. 15.04(1)(m)]. <br /> ��Q'" yl,`� ❑Check it revisi n to previous application <br /> p State Plan I.D.Number <br /> 1. APPLICATION INFORMATION - PLEASE PRINT ALL INF IMA I N <br /> Property Owner Name P operty Location <br /> �' OB v4 1/4,S T 41 N, R (s E(or W <br /> Property Owner's Mailing Addre L t Number Block Number <br /> 1 �. 3 <br /> City,State Zi Code Phone Number Subdi ision 7rleorCSMNumber <br /> Z� <br /> #ZAi�AM M�1 • �oo ( W b <br /> 11. TYPE LDI : (check one) ❑ State Owned+ ❑ Lity Nearest Road--k47,,9 <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms 'L- village <br /> Town OF DR. <br /> Ill. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo `L 2( o(o 1�g �Q I <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. ❑ Replacement 3. Re lacementof <br /> S stem ❑ P 4. E] Reconnection of 5. ❑ Repair of an <br /> ___ y ________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 /> 1Seepage Bed 21 E]Mound 30❑Specify Type 41 ❑Holding Tank <br /> 1 Seepage Trench. 22❑In-Ground Pressure 42❑Pit Privy <br /> 13❑Seepage Pit 43❑Vault Privy <br /> 14❑System-In-Fill <br /> V1. 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 /> Soo Requ'red sq.ft.) Prop sed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) d evation <br /> Z �- qs. O Feet •8 Feet <br /> VII. TANK Capacity <br /> INFORMATION in gallons Gallons Tanks Manufacturer's Name Prefab. Con-iite Fiber- Plastic Exper_ <br /> New ExistingConcrete strutted Steel glass App- <br /> Tank-Tanks <br /> Tanks <br /> Septic Tank or Holding TankIm <br /> �-� <br /> Lift Pump Tank/Siphon Chamber El I ❑ ❑ 1 ❑ 1 ❑ El <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> PI ber s Name:(Print) Plumber' Signature(N amps) MP/MPRSW Nor: Business Phone Number: <br /> t1 �J j 1� - J <br /> Plumber's Address(Street,City,Slate,Zip Code): <br /> 2,7_7(60 ft4e I< WIF l,�l. $g3 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sani y P rmit Fee (includes Groundwater ateIssued Issuing A ;nigna;tv�re5j <br /> NSt ps)roved SurcIt e Feel <br /> PP ❑Adverse Determination <br /> al S <br /> Adverse Determination � < ` <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.11/97) DISTRI8UTION: Original to County,One copy To: Safety 8 Buildings Division,Owner,Plumber <br />