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Safety and Buildings Divisi n <br /> ' 201 W.Washington Avenue <br /> N*6onsinSANITARY PERMIT APPLICATION p O Box 7302 <br /> In accord with ILHR 83.05.Wis.Adm.Code Madison,WI 53707-7302 <br /> Department of Commerce <br /> • Attach complete plans(to the county Copy only)for the system,on paper not less count !,�l 70 \ <br /> than 8 1/2 x 11 inches in size. ! N <br /> • See reverse side for instructions for completing this application state sanitary Permit umber <br /> ��� 9,� <br /> Personal information you provide may be used for secondary purposes ❑Check if revision to prevlo application <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.N <br /> in O <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION <br /> Properly Owner Namer / Property Location ��� <br /> 1// ' I Oil N �1/4N rJ 1/4,SSS.._. T � ,N, R /,? E(or)(0 <br /> PropertyOwner's Mailing Address Lot Number Block Number <br /> _T 77 70 <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> BUILDING: (check one) ❑ State Owned ❑ ill Nearest Road <br /> • E] Village G.J <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms -3 Town OFCJO® f t!•e f` 70 <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) / <br /> eff <br /> 1 ❑ Apartment/Condo Q ,;2 a S"� 3 © l ` le!507® <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 5_ ❑ Repair of an <br /> System System ------------- Tank Only---------------Existing System ________ ExlstingSystem <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 ❑Seepage Bed 21 2QMound 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 5.Perc. Rate 6. System Elev. 7. Final Grade <br /> Re uired(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevatio <br /> ySj} ` 7S— S -- <br /> 1,015 Feet 1,5k7,P Feet <br /> VII. TANK CapeClty site <br /> INFORMATION in gallons Gallons Tanks Manufacturer's Name Concrete Con- Steel eb ss Plastic App- <br /> IExistin strutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank 01 El El 111:111 <br /> Lift Pump Tank/Siphon Chamber ing w 51 11 1:1 ❑ I ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> 1,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name:(Print) Plumber's Signature:(No tamps) MP/MPRSW No.: Business Phone Number: <br /> p/ <br /> Plumber's Address(Street,City,State,Zip Coder <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> E]Disapproved San rLy Permit Fee Ilnd�udesGroundwater ate ssue Issuing ge t Sig ture( tamps) <br /> ]approved E]Owner Given Initial 2 -Syrebargelee) <br /> Adverse Determination � 7/ <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(8.11/97) DISTRIBUTION: Original 10 County.One copy To: Safety&Buildings Division,Owner,Plumber <br />