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Safe aq di iSsion <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> Vftconsin 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 /> wow <br /> than 81/2 x 11 inches in size.• See reverse side for instructions for completing this application state San tar�yyP6grmitt/NN�umberr9 �3 <br /> Personal information you provide may be used for secondary purposes ❑Ch <br /> revi4ion bfEvZap�lication SIQ <br /> [Privacy Law,s. 15.04(1)(m)). ` <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATI N <br /> Pro Ft 0w er Name L Property Location <br /> 4 � v'T�1 14 %61/4,53 V T3 ,N,R ! -&4Q W �j <br /> Property Owner's Mailing Address Lot Number Block Number <br /> Cit tate Zip Code Phone Number Subdivision Name rCSMNum e� <br /> el Ge o ( - I ` Y I (( II <br /> Ill. TYPE F BUILDING: (check one) ❑ State Owned rt� T7N7atrest <br /> ad <br /> ❑ VII age fiVt�-en o irL� �, <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms Town'OF Y r <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) g� <br /> 1 Apartment/Condo d $ l�-'0() G j U o <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.K New 2. Q Replacement 3, ❑ Replacement of 4_ ❑ Reconnection of S. ❑ Repair of an <br /> _____Syrstem ________System _____________ Tank Only______________ Existing System__________ExistingSyrstem <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 /> 110 Seepage Bed 21 ❑Mound 30❑Specify Type 41 Q Holding Tank <br /> 12 154 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 16. System Elev. 17. Final Grade <br /> Required(sq.ft.) Pro osed(sq.ft.) (Gals/da /sq.ft.) (Min./inch) Elevation <br /> /11 Feet 1,. — Feet <br /> Ca acct <br /> VII. FORMATION in gallo s Total #of Manufacturer's Name Prefab. Con Steel Fiber- Exper <br /> Gallons Tanks concrete glass Plastic App <br /> New Existin strutted <br /> Tanks Tanks <br /> Septic Tank Holding Tank Xb� <br /> I 111L <br /> ❑ ❑ ❑ ❑ <br /> Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ 0 ❑ <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(Pr t) PI mber's Signatur :(N Stamps) MP/MPRSW No.: Y�-;/ <br /> siness Phone Number: <br /> ts-ev Z Z SZ2 C-. <br /> Plumber's Address(Street_IC ,City, tate, C de): <br /> v`^ <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (Includes Groundwater ate IssuedIssuing A e Signatur (No St m <br /> pproved ❑ -767P` <br /> ��urcharge Fee) <br /> Owner Given Initial <br /> Adverse Determination 7S �� <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.11/97) DISTRIBUTION: Original to County,One copy To: Safety B Buildings Division,Owner,plumber <br />