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rvision <br /> Safety and Buildings D <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> � sc�onsinP o Box 7302 <br /> In accord wkh Comm 33.05,Wis.Adm.Code Madison,WI 53707-7302 <br /> Department of Comme-ae <br /> • Attach complete plans(to the county copy only)for the system,on paper not less county UR METr �, )�/I <br /> than 8112 x 11 inches in size. State Sanitary Permit Number' <br /> • See reverse side for instructions for completing this application (it -7 <br /> Personal information you provide may be used for secondary purposes ❑ <br /> []Check it revisio p`reviadplication <br /> [Privacy Law,S. 15.04(1)(m)1. NED State Plan I.D.Number <br /> 1. APPLICATION INFORMATION - PLEASE PRIM REPIII��A`f ION <br /> Pro rty Owrer Name Property Location <br /> U € )AAE DAJ1J ggbV LoT l4,S 4 T /� ,N, R 15 Apor)W <br /> Propert Owner's-Ma In Address Lot Number Block Number <br /> City,State Zip Cod Phone Number Subdivision Name or CSM Number 56/ <br /> WEBS re W1 44g 3 ( 7/5) Phi -117/ ✓o1 /7 zorr <br /> II. F BUILDING: (check one) E] State Owned � Nearest Road <br /> E] Village <br /> Public MI<or 2 Family Dwelling-No.of bedrooms 3m4byvn OF �AG►CSoAI w <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> )a-21 ❑ Apartment/Condo 0)a- <br /> 2 <br /> ❑ 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. 5/New 2. E] Replacement 3. E] Replacementof 4_ E] Reconnection of 5. ❑ Repair of an <br /> ---- <br /> System ________System _____________ Tank Only ------------- Existing System -------- <br /> _ ExistingSystem <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 /> 11seepage Bed 21 ❑Mound 30❑Specify Type 41 ❑Holding Tank <br /> 12 Ej 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 S. Perc. Rate 6. System Elev. 7. Final Grade <br /> Re red(sq.ft.) Pro osed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) c ! Elevati <br /> 450 00 r� 96, 1 Feet 97 Feet <br /> TANKCa aclt <br /> VII. INFORMATION in gallons Total #of Manufacturer's Name Prefab. CorI_ Steel Fiber- Plastic Exper. <br /> New ExistingGallons Tanks Concrete strutted Blass App- <br /> New <br /> Tanks <br /> Septic Tank or Holding Tank /000 /000 ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ <br /> Vlll. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name:(Pr nt) PI mber's Signatur �(N amps) MP/MPRSW No.: Business Phone Number: <br /> l�>apw>J5 - 2�SSSi - 6- 415 <br /> pl mher'sAddless(Stre city"State, ipCo e). 3 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> C]Disapprove( Sanit yPermitFee (Includes Groundwater ate IssuedIssuing Ag nt atu s) <br /> V* rOVed ZSu`harge fee) <br /> pp ❑Owner Given Initial OV <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.4/99) DISTRIBUTION: Original 10 County.One copy To: Safety B Buildings Division,Owner,plumber <br />