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Safety and Buildings Division <br /> Visconsin SANITARY PERMIT APPLICATION 201 a x ashingtonAvenue <br /> 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 County <br /> than 8 1/2 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 ❑Ch ��aSra <br /> eck if revision to previou application <br /> [Privacy Law,s. 15.04(1)(m)]. <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION <br /> PropertOwner Name Property Location <br /> 1/4 1/4,S T N,R 14 E(or&N <br /> PropertyOwner's Maili g Ad rens Lot Nu tuber Block Number <br /> N <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> Ail W1 . ( > Z <br /> I. TYPE OF BUILDING: (check one) ❑ State Owned 11 it " Nearest Road <br /> El Public 1 or 2 FamilyDwelling-No.of bedrooms Town OF Ory D <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo 015 ft <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. p( Replacement 3. [:] Replacement of 4_ E] Reconnection of 5_ ❑ Repair of an <br /> ------Syrstem ----- --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 /> 11Seepage Bed 21 E]Mound 30❑Specify Type 41 E]Holding Tank <br /> 12 WSeepage 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.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> 300 $ 9 7.t'o Feet /00.1 Feet <br /> VII. TANK Capacity <br /> INFORMATION in gallons Total #of Manufacturer's Name Prefab. Site Fiber- plastic Exper <br /> New Existin Gallons Tanks Concrete Con- Steel glass App. <br /> structed <br /> T nks Tanks <br /> Septic Tank or Holding Tank �� ' ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber 1:1 ❑ El 0 <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:( Stamps) MP/MPRSW No.: Business Phone Number: <br /> I S' <br /> Plumber's Address(Street,City,State,Zip Code <br /> IX. COUNTY/DEPAR MENT USE ONLY <br /> ❑Disapproved *anitary Permit Fe des Groundwater ate ssue Issuint S tompsMApproved ❑OwnerGiven Initial � u hargeFee) r/'���UU Adverse Determinatio <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.4/99) DISTRIBUTION: Original to County,One copy To: Safety a Buildings Division,Owner,Plumber <br />