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sic . <br /> Safety and uildings (vision <br /> w,- - SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> ♦�■sconsin In accord with Comm 83.05,Wis.Adm.Code P O Box 7302 <br /> 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. <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> Personal information you provide may be used for secondary purposes �30aT <br /> p ❑Check I revision to previous application <br /> (Privacy Law,s. 15.04(1)(m)]_ <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION- PLEASE PRINT ALL INFORMATION <br /> Property Owner Name Propert Location <br /> L/ar•/< Isc►� MI91/4 ?E 1/4,5 .}. T 3g ,N, R/S E(or)(0 <br /> Property Owner's Mailing Address Lot Number Block Number <br /> y f k�7 x00 live Al W <br /> City, tate Zip Code Phone Number Subdivision Name or CSM Number <br /> �� A 1l.•c r AI 1s"r 0 (tr1- )9itt-7yG d 40 *Gp e S <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned 0 City arest Road 35U <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms � ° Town of�f o/ie -l-ti Nerd61AVe J •'!lt <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax <br /> Number(s) <br /> 1 ❑ Apartment/Condo W <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 online B,if applicable) <br /> A) 1. ❑ New 2. X Replacement 3_ ❑ Replacement of 4. ❑ Reconnection of 5_ ❑ Repair of an <br /> E <br /> ------System--------------System------------------- Tank-----Only------------------ xisting System---------------------Existing System <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 aSeepage 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 /> Sod Required(sq. ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevati9n <br /> 00 d0 ^� �3, 6 Feet (o• ( Feet <br /> TANK Capacit <br /> VII. INFORMATION in gallons Total #of Manufacturer's Name Prefab. Site Con- steel Fiber- Exper. <br /> Gallons Tanks Concrete glass Plastic App <br /> New Existin structed <br /> Tanks Tanks ^ <br /> Septic Tank or Holding Tank QQ "-� / ��LQ t11 ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ I ❑ ❑ ❑ <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:(Print) Plu ri ignature:(N St s) MP/MPRSW No.: Business Phone Number: <br /> to <br /> ZZ-S qS7 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> []Disapprove d Sa777-c) <br /> tar Permit Fee (Includes Groundwater ate IssuedIssu g ent Sigpy t e o stamps) <br /> XApproved rsurcharge ree)❑Owner Given Initial / �J �} C <br /> Adverse Determination / �U <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.4199) DISTRIBUTION: Original to County,One copy To: Safety a Buildings Division,Owner,Plumber <br />