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Viscon'sin <br /> Safety and Buildings Division <br /> 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 Coun/,1�y �� <br /> than 8 112 x 11 inches in size. : (4 <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> C) Sp <br /> The information you provide may be used by other government agency programs E]Chat; If revision to prevlo s application <br /> [Privacy Law,s. 15.04(t)(m)]. State Plan I.D.Nu <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATI N 17 <br /> Pro erty Owner Name /�r°�;erty Location <br /> if^ C. e, ITrL.4 tia,Sa T3 ,N, R /,sE(or <br /> Property Ow er's Mailing Address r Lot Number Block Number <br /> 6 S .cJ i^r S-� •— <br /> Cit ,State 1 / Zip Code Phone Number Subdivision Na a or CSM Number <br /> II. TYPE OF B DING: (check one) ❑ State OwnedIty Nearest Road <br /> ❑ Village <br /> Public 1 or 2 Famil Dwellin No.of bedrooms Town OF /t s- @ .v ri S <br /> III. BUILDIN USE: (If building type is public,check all that apply) Parcel TaxNumbber(s) /1 <br /> 1 E] Apartment/Condo 034 r —l5?/00 _ / �0 <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 Existing 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;Eg�­Iolding 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 /> Required(sq. ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> ov - -'Feet Feet <br /> Ca act <br /> VII. FORMATION in gallons Total #Of Prefab. Site Fiber- plastic Exper <br /> Gallons Tanks Manufacturer's Name concrete con- steel glass App. <br /> New Existin structed <br /> Tanks Tanks C <br /> Septic Tank o �d X7000 J ❑ ❑ ❑ ❑ ❑ <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 /> Plumber's Name:(Printh Plumbe 's Signature:( Stamps) 01 MP/MPRSW No.: Business Phone Number: <br /> Plumber's Ac dress(street,City,State,Zip Code): - l ` , <br /> ,4s ad R �� �I n e.�J ! t, =2-- <br /> IX. <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fey.e�(Includes Groundwater ate s ue Issuing Agent Sign ture o amps) <br /> �pproved E]Owner Given Initial Imo urcnargeFee) <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&Buildings Division,Owner,Plumber <br />