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ZI <br /> Safety and Buildings Division <br /> Also6amsin 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 cou y <br /> than 81/2 x 11 inches in size. <br /> • See reverse side for instructions for completing this application Stalte S Itar Permit 4er V <br /> Personal information you provide may be used for secondary purposes C]Che it revision to previous application U <br /> [Privacy Law,s. 15.04(1)(m)). State Plan I.D.Nu b <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATI N 1iZ Y t <br /> Propert Owner Name Propert Location <br /> Cp E1/a E 1/4,5 20 T N, R 110 E(or) <br /> CD <br /> Propert Owne Mailing Address Lot Number Block Number <br /> w 35 fLp_ .7 <br /> Cit State 1 Zip d Phone N tuberSubdivisi n Name or CSM Number <br /> I_. Z <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ Ity � Nearest Road <br /> Village � <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms Town of <br /> III. UILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo 019 332o 01 400 <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. E] Replacement 3. E] Replacement of 4. E] Reconnection of 5. ❑ Repair of an <br /> -_ System ........System ------------- Tank Only______________ Existing System----------Existing System <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 El Seepage Trench 22❑In-Ground Pressure 4 ❑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 /> 1 35 Feet <br /> Ca act <br /> VII. INFORMATION in gallo s Total #of Manufacturer's Name Prefab Con_ Steel Fiber- Plastic Exper. <br /> New ExistingGallons Tanks Concrete structed glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank 77 ❑ ❑ ❑ ❑ ❑ <br /> Luft 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 /> Plum 's Name:(Print) Plu is ignature:(N Stam s MP/MPRSW NO.: Business Phone Number: <br /> �+fAl¢O vw/tIf f 5- - IS <br /> Plu er's Address(Street,City,St te,Zip Code): <br /> If <br /> IX. COUNTY DEPARTMENT USE ONLY <br /> ❑Disapproved Sa ary Permit Fee pndudesGroundwater ate slue Issuing a igna e( S mps) <br /> rOVed charge Fee) <br /> pp ❑Owner Given Initial ` 7 � <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR SAPPROVAL: <br /> SBD-6398(R.4199) DISTRIBUTION: Original to County,One copy To: Safety 8 Buildings Division,Owner,Plumber <br />