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t <br /> 0��,,l Safety and Buildings Division <br /> *&�ohslfn SANITARY PERMIT APPLIChW&VPIJ 201 W.Washington Avenue <br /> CqN x 7302 <br /> Department of Commerce In accord with Comm 83.05,Wis.Adm.Code n,WI 53707-7302 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County a <br /> than 8112 x 11 inches in size. <br /> • See reverse side for instructions for completing this application State Sanitary Permit Numberk/� <br /> Personal information you provide may be used for secondary purposes ElCha,3, 1�t,__prZus application <br /> [Privacy Law,s. 15.04(1)(m)]. <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION <br /> arty O``�ner Name1 / Property Location <br /> Vla �Jvd JUN j, $aI_\ 0/12 1/4,55 TS N, R W <br /> Property0 ner'sMailingAd ress rr Lot Number Block Number <br /> qqg *, i' L dr <br /> Cit Stat Zip Code Phone Number Subdivision Name or CSM Number <br /> l C / 2_7' W <br /> TYPE OF BUILDING: (check one) ❑ State Owned ❑ C!t� / Nearest Road j <br /> Public � 1 or 2 Famil Dwellin -No.of bedrooms ❑Town of d S 1 rt (*. c!. <br /> 111. BUILDING USE: (if buildingtype is public,check all thatapply) Parcel TaxNumber(s) <br /> 1 E] Apartment/Condo <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. 9 New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> ______System ____ _System _____________ TankOnly________--___ 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 0,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 /> Required(sq.ft.) Pro os d sq.ft.) (Gals/da /sq.ft.) (Min./inch) Q Elevation <br /> (� Feet Feet <br /> Capact <br /> VII. TANK in allons Total #of site <br /> INFORMATION Gallons Tanks Manufacturer's Name Prefab. Con- Fiber- Plastic Exper <br /> New ExistingConcrete Steel glass App <br /> strutted <br /> Tanks Tanks <br /> Septic Ta Holding Tank <br /> Lift Pump Tank/Siphon Chamber ❑ El El El El <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plu beer'S Name:(Print Plu er's Signature (No amps) IMP/MPR <br /> SW No.: Business Phone Number: <br /> /lS oC Z2 X22 1-71'S_ SZ�& — <br /> lumber'sAddress( treet,City'State,Zip C de): // <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sani ry P rmit Fee (includes Groundwater ate IssuedIssuing a Signa re a ps) <br /> pproved ❑Owner Given Initial 9e Fee) <br /> Adverse Determination 7s N 36 <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 />