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Vislitionsin <br /> Safety and Buildings Division SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> 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 8112 x 11 inches in size. t1 C=.)/-//9y <br /> n , <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> Personal information you provide may be used for secondary purposes3 '073Q D 7 <br /> [Privacy Law,s. 15.04(1)(m)]. ElCheck if revision to previous application <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION I --- <br /> Propertv Owner Name Property Location <br /> MAr 1/4 1/4,S Z T 4o ,N, R I(. E(o W <br /> Property Owner's Mailingress Lot Number <br /> A g)gC,�„ypm�r <br /> 31 51-_ <br /> Cit ,State Zip Code Ph ne Number Subdivision Name or CSM Number <br /> W� ( IS> <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ ity Nearest Road <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms _� W village Town OF M_ 9RD . <br /> � C1.Iq <br /> III. BUILDING USE: (If building type is public,check all thatapply) Parcel Tax Number(s)1 ❑ Apartment/Condo 0:Z0 Af3o-2 <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 /> S ❑ 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 <br /> Exlstln System <br /> ------------- ------------ y-------------- istinq <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,jSeepage 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 /> Rerur��sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) p Elevation <br /> S '�" l 3 -1 Feet 96. Feet <br /> VII. TANK Capacity <br /> INFORMATION in gallons Total #of Manufacturer's Name Prefab. Site Fiber- plastic Exper. <br /> New Existing Gallons Tanks Concrete Co^ Steel glass App. <br /> Tanksi Tanks I I <br /> structed <br /> Septic Tank or Holding Tank 13 11 <br /> Lift Pump Tank/Siphon Chamber ❑ El ❑ Il <br /> Vlll. RESPONSIBILITY STATEMENT <br /> 1,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plu bar's Name:(Print) Plumber's Signature:(N Sta s) MP/MPRSW No.: Business Phone Number: <br /> tctltl�in Pv/✓3 2 ���- s <br /> PI mber'sAddress(Street,City,State Zip Code): <br /> Z t l_ <br /> IX. COUNTY/DEPARTMEN USE ONLY <br /> ❑Disapproved Sanit�ryPermitFee (Includes Groundwater ate IssuedIssuing tSig tur oStamps) <br /> Approved f5[ Surcnargeree) <br /> pP ❑Owner Given ✓/S r� <br /> Adverse Determination / <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-8398(R.4/99) DISTRIBUTION: Original to County.One copy To: Safety&Buildings Division,owner,Plumber <br />