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*6�nsin <br /> Safety and Buil gs vis SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> In accord with ILHR 83.05,Wis.Adm.Code P O Box 7302 <br /> Department of Commerce Madison,WI 53707-7302 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County <br /> than 8 1/2 x 11 inches in size. <br /> • See reverse side for instructions for completing this application State Sanitary Permit Num/bb r7 <br /> Personal information you provide may be used for secondary `� �( <br /> Y p y ry purposes <br /> (Privacy Law,s. 15.04(1)(m)]. ❑Check if revision to previous appli tion r� <br /> State Plan I.D.Number V <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION <br /> Pr ertY Owner N a3 ( c Property location <br /> h Y� "':y <br /> so / ►� 5 6/4561/4,S j Z T y1 ,N, R IS"F.{ef)W <br /> Property Owner's Mailing Address ` Lot Nu r Block Number <br /> Al <br /> City,State Zip Code Phone Number 5 ivi m Nam rCSMNumber <br /> PA -S 2 t� ((da )d5-a;n 0 7 V Y Y Plot' <br /> 11. TYPE OF BUILDING. (check one) ❑ State Owned 0 city Nearest Road <br /> El Public 1 or 2 FamilyDwelling- No.of bedrooms ❑rowan OF S <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo 03c;L S,;�Is- 03 DO <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 _________Existing System <br /> B) 11A 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 M Seepage Bed 21 []Mound 30 E3 Specify Type 41 E]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 /> Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> "o . Feet I Feet <br /> Ca aclt <br /> VII INFORMATION in gallons Total #of Manufacturer's Name Prefab. cow steel Fiber- Exper. <br /> Gallons Tanks Concrete glass Plastic App <br /> New Existin structed <br /> Tanks Tanks <br /> eptic Ta k or Holding Tank j t ❑ ❑ ❑ ❑ ElI urnpTank/Siphon Chamber El El El 11 11 <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibil ty for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name:( rin Plu ber'sSi nature tamps) MP/MPRSWNo.: Business Phone Number: <br /> l.$ F "Mer <br /> Plumber'sA d ess Street,CLt ,5tate,Zi Cde): <br /> IX. COUNTY/DEPARTMENT USE ONLY , '( <br /> ❑Disapproved Sanitary Permit F dudes Groundwater ate ssue Issuing Agent iatur o St p <br /> pproved ❑Owner Given Initial !J urcharge Fee) ^ <br /> Adverse Determination ( �,1f/ <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.11197) DISTRIBUTION: Original to County,One copy To: Safety 8 Buildings Division,Owner,Plumber <br />