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Safety and Buildingssion <br /> VisIonsin SANITARY PERMIT APPLICATION 201 E.Washington Ave. <br /> In accord with ILHR 83.05,Wis.Adm.Code P.O.Box 7969 <br /> Department of Commerce Madison,WI 53707-7969 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County <br /> than 81/2 x 11 inches in size. r .2a��0 <br /> See reverse side for instructions for completing this application state Sanitary per(, it Nu ber <br /> The information you provide may be used by other government agency programs 3 3`� <br /> [Privacy Law,s. 1 5.04(1)(m)]. ❑Chec revision to previous application <br /> State Plan I.D.Numb r <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION I '- <br /> Propert caner Na Property Location <br /> 1/4 1/4,5 T40 N, R /$ E(o <br /> Property Owner' Maili g Addre s Lot Number1�c� Block NumL�e r <br /> l 1(• 48- msec l- kl[& `eal o k; <br /> City KDALState f W. <br /> Zi Code P one Number Subdivifion Name or CSM Number <br /> 6xuuk�p -F <br /> II. TYPEOF BUILDING: (check one) ❑ State Owned ❑ +.t��( Nv est Road <br /> IFV -10 <br /> Public 1 or 2 Famil Dwelling-No.of bedrooms 3 vd age AC�K,���,�/ �,f� � W/} <br /> Sown OF��t l�7G7N CJY <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Numbber(s) C� <br /> 1 ❑ Apartment/Condo a` J 77500 <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. )a New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> ------System --------System ------------- Tank Only ----- Existing System Exi sting System <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 ❑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 /> A,�, Required(sq.ft.) Pro osed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Eleva on <br /> 46D 6dc3 S6 ,I O'er ' q3Feet Feet <br /> VII. TANK Capacity <br /> INFORMATION in gallons Total #of Manufacturer's Name Prefab. Site Fiber- plastic Exper <br /> New Existin Gallons Tanks Concrete Con- Steel glass App. <br /> strutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank Iwo ® El ❑ ❑ 1 El El <br /> Lift Pump Tank/Siphon Chamber El I El <br /> Vlll. 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 Signatur :( Stamps) MP/MPRSW No.: B siness Phone Number: <br /> 12.2-45 /5- dopav <br /> P mber's Ar dress(Street,City,State,Zip C de). <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved nitary Permit Fee (includes Groundwater ate sue Issuing) a ignat e N ps) <br /> Approved urcharge Fee) <br /> PP El Given Initial � /�- <br /> Adverse Determination ./• <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.11/96) DISTRIBUTION: Original to County,One copy To: Safety a Buildings Division,Owner,Plumber <br /> I <br />