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Safety and Buildings Division <br /> Viscons <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> �n P O Box 7302 <br /> Department of Commerce _in accord with Comm 83.05,Wis.Adm.Code Madison,WI 53707-7302 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County <br /> than 81/2 x 11 inches in size. v <br /> Sta a Sanitary Permit Number <br /> • See reverse side for instructions for completing this application 3 <br /> Personal information you provide may be used for secondary purposes ❑Check it�evl�n`10 previous application <br /> (Privacy Law,s. 15.04(i)(m)1. State PlanI_D <br /> Aumber <br /> I. APPLICATION INFORMATION- PLEASE PRINT ALL INF RMATION <br /> Property Owner Name kJAProperty Location <br /> LLS 1/a 1/4,S 2j T Sq N, R 117 E(orW <br /> Prope y Owner's Mailin Address Lot Number Block Number <br /> - 1 <br /> Cit ,State - Zi Code Phone Number S r #_ <br /> 3 ( IS > O <br /> II. P F BUILDING: (check one) ❑ State Owned I.ty Nearest Road q !� <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms D wan OF t��.ICA1-J� K <br /> III. BUILDING USE: (if building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo ot(0 2j o <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.MReplacement 3, ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> System _ System -_ __ _ __Tank Only - __ _ _____ Existing System __ __ ExistingSystem <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)d 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 /> Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> �O S ✓ S Feet qj.3 Feet <br /> VII. TANK Capacit <br /> in allons Total #of Manufacturer's Name Prefab. con Steel glass <br /> Plastic App <br /> - <br /> INFORMATION New Existin Gallons Tanks concrete strutted <br /> T nks Tank ❑ <br /> Septic Tank or Holding Tank ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber <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 Signature: No raps) MP/MPRSW No.: Business Phone Number: <br /> Plumber's Name:(Print) 9 /^�� I(S_ _ 5-1 <br /> 77j 1 1 <br /> Plumber's Address(Street,Cit ,State,Zip Code): <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> Disa roved Sanpry Permit Fee (Includes Groundwater ate ssue Issuing Agent Si natur No p ) <br /> ❑ pp surcharge Fee) <br /> pproved ❑Owner Given Initial /7�� oZ—/'�O <br /> Adverse Determination / <br /> X. CONDITIONS OF APPROVAL/REASONS F R DISAPPROVAL: 7 o3 <br /> J <br /> DISTRIBUTION: Original to County.One copy To: Safety&Buildings Division,Owner,Plumber <br /> SBD-6398(Rf N99) <br />