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Vh <br /> Safety and Buildings Division <br /> onsin SANITARY PERMIT APPLICATION 201 W.Washington Avenue <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 �StauetSanrjaryPe�r�mit <br /> n <br /> than 81/2 x 11 inches in size. <br /> • See reverse side for instructions for completing this application tmNuum, er <br /> Personal information you provide may be used for secondary purposes `^`� l� <br /> [Privacy Law,s. 15.04(1)(m)]. ❑Check it revision to previous application <br /> I. APPLICATION INFORMATION- PLEASE PRINT ALL INFORMATION State Plan I.D.Number <br /> Propert Owner Name P perty Lo ation <br /> O /77 4- ��a �1/4,S 35 T y� ,N,R/� E(or <br /> Property wn is Mailing Addr ss Lot Nu r Block Number <br /> Cit ,State Zi Co Phone Number Name or CSM Number <br /> L« ( > 9 <br /> II. I YPIE OF BUILDING: (check one) ❑ State Owned ❑ Lity t Nearest Road <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms ❑ village <br /> Town OF3�/rsV�4— <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo 6 <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 1 ❑ Replacement of 4. E] Reconnectionof 5. ❑ Repair of an <br /> ------System --------System ------------- Tank Only---------------Existing System stem Existin$ y <br /> 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 /> 11 45eepage 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 /> 3 Min./inch)Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) ( o Elevation <br /> 6 Feet 92eet <br /> VII. TANK Capacity <br /> INFORMATION in gallons Total #of Manufacturer's Name Prefab. Site Fiber- Exper. <br /> New Existing Gallons Tanks Concrete Con- Steel glass Plastic App <br /> T nks Tanks strutted <br /> Septic Tank or Holding Tank lew I 0 /t/orw - ;, ❑ El El ❑ 0. El <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ <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 /> ,90;s< �i X;— ,--) G✓ 7 2 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> E]Disapproved Sanitar Permit Fee (Includeseroundwater ate ssue Issuing gentSignatu�amps) <br /> )(Approved ❑Owner Given Initial _41{(y � surcharge Fee) <br /> Adverse Determination <br /> X. COFNDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.4/99) DISTRIBUTION: Original to County.One copy To: Safety&Buildings Division.Owner,Plumber <br />