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Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION 271 W.Washington Avenue <br /> ■ P O Box 7302 <br /> isconsin 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 County <br /> than 8 1/2 x 11 inches in size. o <br /> St a Sanitary Permit Number <br /> • See reverse side for instructions for completing this application 301 / / us application <br /> 53 <br /> Personal information you provide may be used for secondary purposes [0]Check it revision to prevl <br /> [Privacy Law,s. 15.04(1)(m)]. State PI ril.L1.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATIONPro1l1 <br /> Prope wrier Na`#� gl/4ert Location <br /> S T ,N,R E(or W <br /> J. <br /> Propert Owner's Mailing dress Lot Number Block Number <br /> City,State Z�iode _ Phone Number Subdivision Name or CSM Number <br /> LVt '�TQD�•Z0 ( ) <br /> I, P DING: (check one) ❑ State Owned Ll Lilly N�ea`rest Road <br /> ❑Village SCrFjTW . 4 <br /> Public 1 or 2 FamilyDwelling-No.of bedroomsA. Town OF <br /> Parcel Tax Number(s) <br /> III. BUILDING SE: (If building type is public,check all that apply) L 3ZD <br /> 1 ❑ Apartment/Condo <br /> 2 E] Assembly Hall 6 ❑ 10 Medical Facility/ 11 ❑ Outdoor Recreational Facility <br /> 3 E] Campground 7 E] Merchandise:Sales/Repairs C] Restaurant/Bar/Dining <br /> 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash <br /> 5 ❑ Hotel/Mote[ 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 S. ❑ Repair of an <br /> S stem System ---------____ Tank Only _____________ Existing System ____--_ ExlstingSystem <br /> System <br /> Date Issued <br /> B) ❑ A Sanitary Permit was previously issued. Permit Number <br /> V. TYPE OF SYSTEM: (Check only one) <br /> Non-Pressurized Distribution Pressurized Distribution Experimental Other <br /> 11 []Seepage Bed 21$Mound 30❑Specify Type 41 E]Holding Tank <br /> 12 E]Seepage Trench 22❑ Pressure Pre 42❑Pit Privy <br /> 43 Vault Privy <br /> 13❑Seepage Pit <br /> 14❑System-In-Fill <br /> VI. ABSORPTION SYSTEM INFORMATION: <br /> 1.Gallons Per Day 2. Absorp.Area 3. Absorp.Area 4. Loading Rate 5.Perc. Rate 6. System Elev. Elev7. lation nal Grade <br /> Req ired(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) �6. (p Feet .$ Feet <br /> 2400 <br /> VII. TANK Capacity Total #of site Plastic <br /> in gallons Manufacturer's Name Prefab. Con- steel Fib ss Aper. <br /> INFORMATION New Existin Gallons Tanks concrete structed g <br /> Tanks Tanks <br /> Septic Tank or Holding Tank ❑ ❑ 0 <br /> �� %% 0 <br /> I El <br /> Lift Pump Tank/Siphon Chamber <br /> Iwo <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 ps) MP/MPRSW No.: Business Phone Number: <br /> (Y <br /> 57 <br /> umber's Address(S reet,city,State,Zipcode) <br /> 11 IF1..� <br /> 350 in ksm- <br /> IX. COUNTY/ DEPARTMENT SE ONLY <br /> ❑Disapproved Sa tar Permit Fee II"°udesGroundwater 11151 ue Issuing e Sign ur�o a s) <br /> charge Fee) I/ a, <br /> Approved ❑Owner Given Initial , <br /> Adverse Determination <br /> 1. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: _ -co <br /> DISTR18UTION: original to county.One copy To: Safety&Buildings Division,Owder,Plumber <br /> SBD-6398(R.11/97) — — <br />