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Safety and Buildings Division <br /> Visconsin SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> 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 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 ❑Check if revision to previous application h ^, <br /> [Privacy Law,s. 15.04(1)(m)1. State Plan I.D.Number,►/� CI. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATI N �//// <br /> Property wner me Property Location <br /> 1/4 1/4,S T40 N, R 14 E(or <br /> ProperfyOwner's ailing��yAAdd�dr ss Lot Number r <br /> 2_q 2W- <br /> Cit ,State Zip Code Phone Number Subdivisi n Name or umber <br /> LiI- ( ) vm� a a <br /> II. TYPE L ING: (check one) ❑ State Owned city Nearest Road <br /> ❑ Village <br /> Public 1 or 2 Family Dwelling-No.of bedrooms Town OF <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNuumber(s) <br /> 1 F1 Apartment/Condo MA 4i OA- M 6P00 <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,gReplacement 3, ❑ Replacement of 4. ❑ Reconnection of 5_ ❑ Repair of an <br /> ____ System -__ System Tank Only __ __ __ ExistingSystem _ ____ 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 /> 11Seepage Bed 21 ❑Mound 30 E]Specify Type 41 C-]HoldingTank <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 1 6. System Elev. 7. Final Grade <br /> Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) levation <br /> !,� 2 q1-0 Feet Feet <br /> Ca at <br /> VII INFORMATION in ga los Total #of Manufacturer's Name Prefab. Con Steel Fiber- plastic Exper <br /> New Existin Gallons Tanks concrete structed glass App. <br /> T,anks Tanks <br /> Septic Tank or Holding Tank ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ <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: S ps) MP/MPRSW No.: Business Phone Number: <br /> C14)WO Kin15 � SS51 IS- - /S <br /> PI tuber's Address(Street,City ate,Zip Code): <br /> D 1�)r45614913 <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> X�ApproveclDisapproved Sanitary Permit Fee (includes Groundwater ate ssue Issuing entSgnature(NoStamps) <br /> surcharge Fe )❑Owner Given Initial al l'rlcj. UD �_ �—�� <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.11/97) DISTRIBUTION: Original to County.One copy To: Safety 6 Buildings Division,Owner,Plumber <br />