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% SAM Bui Division <br /> A SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> N %SConsin 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 =Number <br /> ��� <br /> than 81/2 x 11 inches in size. rly <br /> • See reverse side for instructions for completing this application Sanitary mit Number937Personal information you provide may be used for secondary purposes to previous application[Privacy Law,s. 15.04(1)(m)]. mber`I. APPLI ATION INFORMATI N - PLEA E PRINT ALL INF RMATI N /�^� <br /> Proprty Owner Name /Prpperty Location <br /> i1 rq t9 (_T,&4, 3 1/4,S Z y T G ,N, R/J- E(orr <br /> Property Owner's Mailing AddressLot Nun*ber Block Number <br /> U 47—C^ Gia , <br /> Civ,itlate Zip Code Phone Number �y Subdivision Name or CSM NumJ�er <br /> (ray! l-/W/ n f ,a <br /> 11. TYPE OF BUILDING: (check one) ❑ State Owned ❑ CNearest Road d <br /> [3 Village <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms Town OF Lu <br /> III. BUILDING USE: (if buildingtype is public,check allthatapply) Parcel TaxNumber(s) <br /> &62 - a -Q3 adv <br /> 1 ❑ 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 online B,if applicable) <br /> A) 1. ❑ New 2. ® Replacement 3. E] Replacement of 4. E] Reconnection of 5. E] Repair of an <br /> System _ _ System -_-__ ___ Tank Only -___ ____ _ ExistingSystem _ _______ExisUnc�System <br /> ----------------------------------- <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 �/ o 43 E]Vault Privy <br /> 14❑System-In-Fill jfCHc/7 14,1 ow IfY � .� <br /> VI. ABSORPTION SYSTEM INFORMATION: <br /> 1. Gallons Per Day 2. Absorp.Area 3. Absorp.Area 4. Loading Rate S. Perc. Rate 6. System Elev. 7. Fina[ Grade <br /> �� Reqtuired (sq.ft.) Proposed(sq.ft.) (Gals/daY/sq.ft.) (Min./inch) Elevation <br /> J 'z r Z of . � Feet Feet <br /> VII. TANK Capacity Site <br /> in gallons Total #of Manufacturer's Name Prefab. con- steel Fiber- plastic Exper <br /> INFORMATION New Existing Gallons Tanks Concrete strutted glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank 1 A&Z) Gvr?SeEl n n n <br /> 1-1 <br /> Lift Pump Tank!Siphon Chamber I I 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 /> PI er'sNa :(P t) Plumb 'sSignat oSt ps) MP/MPRSWNo.: Business Phon Number: <br /> Plumber's Address ddress(Stree City,Stat ,Zip Cod ): 1. lr• / <br /> c // /G f� <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑DISd roved Sani ryPermitFee (includesGround water ate ssue Issuing Sin ure &oams) <br /> PP � �� Surcharge Fee) �� r <br /> pproved ❑Owner Given Initial -d G7 <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> DISTRIBUTION: original to county.One copy To: Safety&Buildings Division,Owner,Plumber <br /> SBD-6398(R.4/99) <br />