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r,7Z c-o� <br /> SANITARY PERMIT APPLICATION Safety and Buildings Division <br /> Asconsia <br /> 201 E.Washington Ave. <br /> In accord with[LHR 83.05,Wis.Adm.Code Box <br /> Department of Commerce Mad Madison,WI WI 53707-7969 <br /> on elli <br /> • Attach complete plans(to the county Copy only)for the system,on paper not less County p <br /> than 8 112 x 11 inches in size. ry Or+-r <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> �, 3 g <br /> The information you provide may be used by other government agency programs / ❑Check i revis on to previous a plication <br /> [Privacy Law,s. 15.04(1)(m)1. �pUl W <br /> v60 State Plan I.D.Nu er <br /> 1. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION 9 <br /> Property Owner Name I Property Location <br /> S T A1,0 ,N, R 16 E(or <br /> Pro erty Owner's Mailing Address Lot Number Block Number <br /> f <br /> City,State Zip Code Phone Number Subdivision Name or N of �� <br /> RdW/j 4EGc> Mi / <br /> I. TYPE OF BUILDING: (check one) ❑ State Owned '0'❑ vi!ti(age N15arest Road <br /> Public XL 1 or 2 Family Dwelling-No.of bedrooms Town OF Oftk L <br /> III. BUILDING USE: (if buildingtype ispublic,check allthatapply) Parcel TaxNNuumbeerr(s) <br /> 1 F-1 Apartment/Condo " �` a — �13/ — tO/7 <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- XNew 2. ❑ 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;RHolding 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.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> � O Feet Feet <br /> VII. TANK Capacity <br /> in gallons Total #OfPrefab. Site Fiber- Plastic Exper <br /> INFORMATION New Existing <br /> Gallons Tanks Manufacturers Name Concrete Con- Steel glass App. <br /> Tanks Tanks r strutted <br /> Septic Tank o olding Tank AQ Q V*VE ` UR Il Q r_1 ❑ El <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) / Plumb gnature:(No Stamps) MP/MPRSW No: Business Phone Number: <br /> Cy�1 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> P f (s o 1 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit f,21� (includes Groundwater ate IssuedIssuing Agent Signature N tamps) <br /> qrroved �y!{ Surchargeree) <br /> ❑Owner Given Initial 50 <br /> Adverse Determination cc// T <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.11/96) DISTRIBUTION: Original to County.One copy To: Safety 8 Buildings Division,Owner,Plumber <br />