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Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION 201 E.Washington Ave. <br /> `*isconsin In accord with ILHR 83-05,Wis.Adm.Code P.O.Box 7969 <br /> Madison,WI 53707-7969 <br /> Department of Commerce <br /> • Attach complete plans(to the county copy only)for the system,on paper not less Cou ty <br /> than 8 112 x 11 inches in size. �n <br /> • See reverse side for instructions for completing this application State Sanitary Permit Numb <br /> The information you provide may be used by other government agency programs ❑Check it on to prev�ds application <br /> 5 <br /> (Privacy Law,s. 15.04(1)(m)1. State Plan 1�umber <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION t <br /> PropprQy Own Name Property Location <br /> l/J-"rS. �o�' SO � 3�a,S 12 T3-7 .R lg E(or)� <br /> Property Qwner's�ng Addres c� Number_ Block Number <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> II. TYPE BUILDING: (check one) ❑ State Owned Cl it� Nearest Road <br /> ❑ Vii age / Y,. La/CC <br /> Public 1 or 2 FamilyDwelling-No-of bedrooms Town of GGs <br /> 111. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo <br /> —OF, .�©6 <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. 5f Replacement 3_ ❑ Replacement of 4. ❑ Reconnection of 5_ ❑ Repair of an <br /> System _ System _ _ Tank Only .............Existing System ________ 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 /> 11 ❑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 2. Absorp.Area 3. Absorp.Area 4. Loading Rate 5.Perc. Rate 6. System Elev. 1 7. Final Grade <br /> Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> Sao 1 1 11 Feet Feet <br /> VII. TANK Capacity <br /> in gallons Total #of Manufacturer's Name Prefab. co Steel Fiber- plastic Exper. <br /> INFORMATION New Existing <br /> Gallons Tanks Concrete structed glass APP <br /> Tank Tanks <br /> Septic Tank or Holding Tank <br /> Lift Pump Tank/Siphon Chamber Ei Q Q El El ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plu ber'sName:(Print) Plu "s Sign re' No it mps) MP/MPRH.: Business Phone Number: <br /> Plumber's Address(Street,City,State,Zip Code): <br /> Sf J clef CrGJr ,3"y�3 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disa roved S taryPermitFee (IncludesGroundwa[er ate slue Issuing entSignature(No Stamps) <br /> pp Surchargefee) n <br /> pproved ❑Owner Given initial '� oo �- /- d{� <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> DrSTRRUTM: Original to County,One copy To: Safety 8 Buildings Division,Owner.Plumber <br /> SBD-6396(R.11196) <br /> i <br />