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Safety and Buildings Division <br /> %sconsin SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> P O Box 7302 <br /> Department of Commerce In accord with Comm 83.05,Wis.Adm.Code Madison,WI 53707-7302 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County 3 sod 7 <br /> than 81/2 x 11 inches in size. 5tcati4ft-r-, a2 <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> 53C5<ot� J <br /> Personal information you provide may be used for secondary purposes L]Check I evision to previous application <br /> IPrivacy Law,s. 15.04(1)(m)]- State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATI N (067P <br /> Pro Owner Name Property Location <br /> Iia 1/4,S 3S T ,N, R �(o E(or(W) <br /> Property Owner's Maiing Address Lot Numberr <br /> _ .tom- <br /> "I <br /> City,State Zip Code P one Number Subdivision Name or CSM Number <br /> L ((,-SI ) ' V- IS P. <br /> It. BUILDING: (check one) E] State Owned 'ty Nearest Road <br /> ❑ Village <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms -3 Town OF O i 1b <br /> III: BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo I D20 03 (002- <br /> 2 <br /> 0022 ❑ 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. Is6 New 2. E] Replacement 3. E] Replacementof 4. E] Reconnection of 5. E] Repair of an <br /> ______System --------System ------------- 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 21OMound 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.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> 1. 12- �—� �P.� Feet Q$-G Feet <br /> Ca aclt <br /> VII. INFORMATION in Allo s Total #of Prefab. Site Fiber- Ezper. <br /> g Gallons Tanks Manufacturer s Name concrete Con- Steel glass Plastic App <br /> New Existingstrutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank (000 ❑ El El ❑ <br /> Lift Pump Tank/Siphon Chamber (pOp+>�_ & rl D I 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 /> Plumber's Name:(Print) Plumber's Signature:(No St ps) MP/MPRSW No.: Business Phone Number: <br /> ZC4A92 <br /> Plu ber's Address(Street,City,State,Zip Code): <br /> 2"1-7 104D w 3s hI>C,BS'T>�R I,JI_ g3 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sa itary Permit Fee (includesGroundwaterate sue Issuing ge Signa re(N ps) <br /> d},4}� roved Surcharge Fee) <br /> V p ❑OwnerGi eterminz � 0 Q� X <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.4/99) DISTRIBUTION: Original to county.One copy To: Safety 8 Buildings Division,Owner,Plumber <br />