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Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION 201 E.Washington Ave. <br /> ■Sfr Y/��51�■ 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 County anal <br /> than 8112 x 11 inches in size. <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> The information you provide may be used by other government agency programs ❑Check re�� ions' application <br /> lication <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION <br /> Property Owner Name Property Location <br /> L W 1/4 114,5 TAf IN,R E-(er)W <br /> Property Owner's Mailing Addres Lot Number Block umber <br /> in- AVX A//A A14 A <br /> City,StatbI Code Phone Number Subdivision Name or CSM Number <br /> _54 no ( -78 N/1A <br /> TYPE OF BUILDING: (check one) ❑ State Owned o vlage Nearest Road u f/ <br /> Public 5f 1 or 2 FamilyDwelling-No.of bedrooms VdTown OF r 11155 E 3 <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 037 _<S - (933001 ❑ Apartment/Condo <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] Replacementof 4. E] Reconnection of 5. E] Repair of an <br /> System __ System _ __ _ _ Tank Only ____________ Existing System _ 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 /> 11 ASeepage 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 13. Absorp.Area 4. Loading Rate 1 5.Perc. Rate 6. System Elev. 7. Final Grade <br /> Required(sq-ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> y�0 6 rX`zr �(o Z,4 Feet Feet <br /> VII. TANK Capacity Site <br /> in gallons Total #Of Manufacturers Name Prefab. Con- Steel Fiber- plastic Expp. <br /> INFORMATION Gallons Tanks concrete glass App. <br /> New Existin strutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank 0 d0 O_ �bOd ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber 41001--o' `OD ❑ ❑ ❑ 1 ❑ ❑ <br /> Vlll. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumb Name:(Print) Plumbe ' Signature:( mps) /MPRSW No.: Business Phone Number: <br /> Plumber'sA dress( reet,City,State,Zip e)�Sg <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (Includes Groundwater ate ssue Issuing Age t Signa re(N St PS) <br /> /�o -OV <br /> Approved ❑Owner Surcharge Fee) <br /> Given Initial <br /> Adverse Determination /t'O <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD41M(R 11/a6) DISTRIBUTION: Original to County.One copy To: Safety 8 Buildings Division,Owner,plumber <br /> u.� <br />