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Safety and Buildings Division <br /> `�= SANITARY PERMIT APPLICATION 201 E.Washington Ave. <br /> �sconsin In accord with ILHR 83.05,Wis.Adm.Code P.O.Box 7969 <br /> Department of Commerce Madison,WI 53707-7969 <br /> 0 Attach complete plans(to the county copy only)for the system,on paper not less County <br /> than 8 tie x 11 inches in size. v <br /> See reverse side for instructions for completing this application State Sanitary i Number <br /> The information you provide maybe used by other government agency programs ❑Check it&vision to previous application <br /> (Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Pro erty Owner Name Property Location <br /> ' �/ fow Sp W*S w 1/4,S i 7 T yl ,N, R/S`E(or 6 <br /> Pro erty Owner's Mailing Address Lot Number Block Number S <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> II. TYPE OF BUILDING: (check one) ❑ State Ownedityy Nearest Road / <br /> ❑ Village amiss ®2d G/ <br /> Public 1 or 2 FamilyDwelling- No.of bedrooms � own oF.s Lk <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo 0 3z G <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_ gLReplacement 3_ ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair af,an <br /> ------System --------System _____________ TankOnly________----_ Existing System----------Existing System <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 ❑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 /> t� Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) - Elevation <br /> Feet 9�,y Feet <br /> Ca aclt <br /> VII. Site <br /> FORMATION in gallons Total #of Manufacturer's Name Prefab- Con- Steel Fiber- plastic Exper <br /> New Existin Gallons Tanks Concrete strutted glass App- <br /> Tanks I Tanks <br /> Septic Tank or Holding Tank laoo 1 1000 91 ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber 00 ❑ ❑ ❑ ❑ ❑ <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:(PUnt) - Plumber's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> Plumber's Ac dress(Street,City,State,Zip Code): 7 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved ar Permi�(Inclu sGroundwater ate ssue Issuing tSi u <br /> roved ge Fee) �S <br /> pp In Given Initial <br /> Adverse Determination f <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-8398(R.11/96) DISTRIBUTION: Original to County.One copy To: Safety&Buildings Division,Owner,Plumber <br />