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Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> Vftconsin In accord with ILHR 83.05,Wis.Adm.Code P O Box 7302 <br /> Department of Commerce 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. a �a <br /> • See reverse side for instructions for completing this application state Sanitary mint Number <br /> Personal information you provide may be used for secondary purposes ❑Check3f revision t�vVus application <br /> IPrivacy Law,s. 15-04(1)(m)]. State Plan I.D.Nu2WF\_,_� <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATI N <br /> PropertyOwnerName . �roperty Lipication <br /> 1/4 NW 1/4,S 7,+ T ,N, R lb E(orig <br /> Prorty Owner's Mailin Addre of Number Block Number <br /> Cit , tate Zi Code Phone Num r Subdivision Nam or CSM Number <br /> 5461II. TYPE OF BUILDING: (check one) ❑ Stat Owned 3 ° v ty la e N rest Road <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms own o iQ_ <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo 1 634 157-4 01 loo <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. U Replacement 3_ ❑ Replacement of 4. ❑ Reconnection of 5. [:] Repair of an <br /> ------System --------Sysstem ............. TankOnly _________. Existing 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 '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. 7. Final Grade <br /> ,(�,, Required(sq.ft.) Pro sed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) A Elevation <br /> 4sb 7 3• Feet Z Feet <br /> Capaclt <br /> VII. TANK in Ballo s Total #of Prefab. Site Fiber- Exper. <br /> INFORMATION New Existin Gallons Tanks Manufacturer's Name Concrete co" steel glass Plastic App- <br /> s <br /> Tanks Tanks <br /> Septic Tank or Holding Tank �- Z�JR ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber El 1:1 1:1 El Q <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) Plumber's Signature(N amps) MP/MPRSW No.: Business Phone Number: <br /> crzo �25'SSI :3 <br /> S <br /> P mber's Address(Street,CIitf,State,Zip Code): <br /> W 1. X893 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> []Disapproved I Sanitary Permit Fee <br /> ) (Includes Groundwater Mate ssue Issu ng, gent Signature(No Stamps) <br /> A) 6, <br /> 6`W surcharge Fee) _vn—t(�,,/,1_/'jlf, /I i 4A �) <br /> Approved r_1 Owner Given Initial J �` <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398 IRA 1/97) DISTRIBUTION: Original to County.One copy To: Safety B Buildings Division,Owner,Plumber <br />