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NVIsconsinand Buildings <br /> SANITARY PERMIT APPLICATION 201eW.WashingtonAvenuen <br /> Department of Commerce In accord with Comm 83.05,Wis.Adm.Code P O Box 7302 <br /> 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. <br /> • See reverse side for instructions for completing this application G <br /> p g pp StateSanitaryPermitNY7um er <br /> Personal information you provide may be used for secondary ��� I <br /> purposes J <br /> [Privacy Law,s. 15.04(1)(m)]. ❑Check if revision to pre lou-application <br /> I. APPLICATION INFORMATION <br /> State Plan I.D.Number <br /> - PLEASE PRINT ALL INF RMATI N <br /> Property Owner Name L Property Location c <br /> �OrIN S.,_) 1/4A.)E1/a,5 Tc�/ N R 6 E(o� <br /> Property Owner's Mailing Address Lot Nmbe u <br /> O 7 Block Number <br /> Cit ,State Zip Code Phone Number Subdivision Name or CSM Number <br /> %e-^J avV 1707-5-2.7 3 <br /> I. TYPE BUILDIN (check one) ❑ State Owned U Lily Nearest Road <br /> PublicW.J.or 2 FamilyDwelling-No.of bedrooms 2 ❑ village ` 7 7 <br /> Town OF .SW/$ <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo CP3�75-323 0 fir �v <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, M New 2. ❑ Replacement 3. Re lacement of <br /> �"3 ❑ p 4. ❑ Reconnection of S. Repair of an <br /> System ---- System Tank Only _ _ _ Existing S stem ❑ Exstin System <br /> - --------------------------- ----- 9 y------------------9--y---- <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 ❑Holding Tank <br /> 12 Seepage Trench 22❑In-Ground Pressure 42 E]Pit Privy <br /> 13[]Seepage Pit <br /> 14 43 E]Vault Privy <br /> ❑System-I System-In-Fill l <br /> VI. ABSORPTION SYSTEM INFORMATION: <br /> 1.Gallons Per Day 2. Absorp.Area 3. Absorp.Area 4. Loading Rate S. Perc. Rate 6. System Elev. 7. Final Grade <br /> Z o O Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) q Elevation <br /> �a 91 / Feet 9T'.3 Feet <br /> VII. TANK Capacity <br /> INFORMATION in gallons Total #of Prefab. site Fiber- Ex <br /> New ExistingGallons Tanks Manufacturer's Name Concrete Con- Steel Plastic per <br /> T nks Tanks <br /> strutted glass App- <br /> Lift <br /> Tank or Holding Tank G� 1—:1 <br /> ❑ ❑ ❑ 1—:1 <br /> Lift Pump Tank/Siphon Chamber El El ❑ ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> 1,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name:(Print) Plumber's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> Plumber's Address(Street,City,State,Zip Code): <br /> X. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (Includes Groundwater ate -sue Issu g gent$i ature(No Stamps) <br /> Approved ❑Owner Given Initial Surcharge Fee) <br /> Adverse Determination / �o <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.4/99) DISTRIBUTION: Original to County,one copy To: Safety&Buildings Division,Owner,Plumber <br />