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Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> Visconsin - 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 12 x 11 inches in size. 6zneA.C77_ <br /> • See reverse side for instructions for completing this application State Sanitary Permit Numbe <br /> 3�56ft SU <br /> Personal information you provide may be used for secondary purposes E]Check i1 revision to previou application <br /> [Privacy Law,s. 15.04(1)(m)1. State Plan I.D.Nu er <br /> I. APPLICATION INFORMATION- PLEASE PRINT ALL INF RMATION <br /> Property Owner Name Property Location <br /> '6/1/ l-7 T ,N, R (Cl <br /> Property Owner's Mailing Address Lot Number Block Number <br /> .31L-1;23 A-0- <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> II. P BUILDING: (check one) ❑ State Owned 'ty Nearest Road <br /> e <br /> Public 1 or 2 FamilyDwelling ❑-No.of bedrooms �Z- TVllownagof 54075157 Lkl PC) <br /> III. BUILDING U E: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo <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. Replacement 3_ ❑ Replacement of 4. ❑ Reconnection of 5_ ❑ Repair of an <br /> _System ystem ------------- Tank Only---------------Existing System __-----__ExistingSyfstem <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 /> 1 ikeepage 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 /> Require (s .ftJ Propos d(sq.ft.) (Gals/da /sq.ft.) (Min./inch) Elevation4oG' <br /> 300' 3 — 1'2 -2 Feet 9Y/0[Feet <br /> Capact <br /> VII. FORMATION in llons Total #of Prefab. Site Fiber- Exper- <br /> g Gallons Tanks manufacturer's Name Concrete Con- Steel glass Plastic App <br /> New Existin structed <br /> Tanks Tank <br /> Septic Tank or Holding Tank A0 ❑ ❑ ❑ ❑ - ❑ <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 /> Plu Name:(Print) Plum nat re:,(i`'o amp MP/MPRSW No.: Business Phone Number: <br /> 12 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 16 7 l3 s_ 57A-7E )t2-t 3 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (include ate ssue Issuing ge Sign <br /> �� ge Fee) ? <br /> #Aj5proved Owner Given Initial g- <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 8 Buildings Division.Owner,Plumber <br />