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Safety and uilding vision <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> Wisconsin 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 Cou'�Y --II f � <br /> than 8 12 x 11 inches in size. lJ��11 TT r7 <br /> See reverse side for instructions for completing this application State Sanitary Permit Num er �[/J <br /> Personal information you provide may be used for secondary purposes ❑Check it reJ hn�6 pfe;Z;-A kation <br /> (Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number 60 <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION L D, <br /> Prrty O ner N me 1 Property c tion <br /> o e <br /> �M rI -)C Sdtit o I Iia 1/4,S Z T 37 ,N, R r N/ <br /> Propert Owner's Mailing Address Lot Number'C) Block Number <br /> o SoS <br /> �Ay,Stat Zip Code Phone Number Subdivision Name or CSM Number © 0 <br /> t o Z 2 4/ vY1 vt ((o�L Ra$—QZ26 <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned Itr Nearest Road , <br /> ❑ Vilage ii ) �/ c <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms Town OF L , �J F <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax <br /> tter <br /> N/Iumberr((s) <br /> 1 F1 Apartment/Condo OJT 9-/cc 02- /I0 <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. Replacement 3, ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> SystemSystem ------------- Tank Only_____________ ExistingSystem ________ ExistingSystem <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 /> 1 1 ❑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 LReq <br /> bsorp.Area 3. Absorp.Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade <br /> uired(sq.ft.) Proposed( ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> `( Feet <br /> VII. TANK Capacity site <br /> in gallons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. <br /> INFORMATION New Existin Gallons Tanks concrete structed glass App. <br /> Tanks I Tanks <br /> Septic Tank Holding Ta �( �© I f�'�{ ® ❑ 11 <br /> LiftPump Tank/Siphon Chamber 11 El El 11 El ❑ <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 :ber's Nam rint) Plu ber's Signat re: Stamps) MP/MPRSW No.: Business Phone Number: <br /> N ($ 21r f?�� tiC5`� ZLSZZ`i l SV O!�Q� <br /> Plumber's Address(Street ity,State,Z Code): ` � � <br /> 17 C/ tit d (� <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sa itary Permit Fee (Includes Groundwater F;tesue IssuingA n igna e N ps) <br /> Surcharge Feproved ❑Owner Given Initial s� L20-6 <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.4199) DISTRIBUTION: Original to County.One copy To: Safety&Buildings Division,Owner,Plumber — <br />