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`�! Safety and Buildings Division <br /> .Iseonsin SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> 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 system,on paper not less County }-� <br /> than 8112 x 11 inches in size. r 0) >•v oZ3 <br /> • See reverse side for instructions for completing this application State Sanitary Permit Numb r ! 11 <br /> Personal information you provide may be used for secondary purposes <br /> (Privacy Law,s. 15.04(1)(m)]. E]Check if revision to previ us application <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATI <br /> Prop x0 er Name roperty ocation <br /> L -C 11-t— 1/4 1/4,5 3 0 T Y ,N, R 1X_E(orjo <br /> Propert Owners Mailing Addre . .^^ Lot Number' Block Number <br /> h4 at VrL41 I✓/" <br /> Cit tftt�SQl(� Zi Code o' PhoneNumber Subdivi n am or1SNI umber <br /> ( . TYPa F BUILDING: (check one) ❑ State Owned ❑ 't dam, Nearest R d <br /> Public 1 or 2 FamilyDwelling- No.of bedrooms ° rowan OF T �«S 6F fe <br /> III. BUILDING USE: (if building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo D33-- S-!;1 30 <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. ❑ Replacement of 4_ ❑ Reconnection of S. ❑ Repair of an <br /> tem ----- --System ------------- Tank Only ------- Existing System stem Existin- - <br /> 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 /> 11 KSeepage 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 /> Rl�u�d(sq.ft.) Pro q;p ose(sq.ft.) (GaWd y/sq.ft.) (Min./inch) G 9 Ele/��t' <br /> 7 / / -f Feet ( aaGG '^'Feet <br /> VII. TANK Capacity <br /> INFORMATION in gallons Total #of Manufacturer's Name Prefab. Site Con- Fiber- plastic Exper. <br /> New ExistingGallons Tanks Concrete Steel glass App. <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank QOO 0044 .3 Qt J 0 El El I Q 1 1:1 El <br /> Lift Pump Tank/Siphon Chamberl I I Ej 1:1 JJ 1 1:1 1 El El <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) I POVier Sign�-atu�. :(No Stamp MP/MP SW No.: Business Phone Number: <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 3 ? (0,o # 40F9'' <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved San ry Permit Fee includes Groundwater ate ssue Issuing Age t gnatur?(N5 Approved ❑Owner Given Initial r " rgeree)Adverse Determination / <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.4/99) DISTRIBUTION: Original to County,One copy To: Safety&Buildings Division,Owner,Plumber <br />