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Safety and Buildings Division <br /> Visconsin SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> P O Box 7302 <br /> Department of Commerce In accord with Comm 63.05,Wis.Adm.Code Madison,WI 53707-7302 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County -7q <br /> than 8112 x 11 inches in size. lde 1,) /, <br /> • See reverse side for instructions for completing this application State Sanitary Per A u�ee© <br /> Personal information you provide may be used for secondary purposes El Check it re o previous application <br /> IPrivacy Law,s. 15.04(1)(mill. State Plan I.D.Numjr <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATI N /°Z(00 <br /> Property Owner Name eProperty Location c <br /> onJ4 _5 c h 7�_' Z S'td1/4Sr,J 1/4,S /OC> T N• R& E(or)(0 <br /> Property Ow is Mailin Address Lot Number Block Number <br /> City,State ZipCC7ode Phone Number Subdivision Name or CSM Number <br /> YPE OF BUILL)INU: (check one) ❑ State Ownedtr n Nearest Road r <br /> J ��tr <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms TowOF e 0 / a N <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax <br /> �N�umber(s) <br /> 1 ❑ Apartment/Condo 0 /d 3 / a 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. II��New 2. E] Replacement 3. E] Replacementof 4. E] Reconnection of 5. E] Repair of an <br /> "J3ystem _ System _ _ _ Tank Only _ __ _ ExlstingSystem _ __ ExlstingSystem <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[KSeepage Trench 22 E]In-GroundPressure 42❑Pit Privy <br /> 13❑Seepage Pit a20— -/G' 32�vl,,, g43 Q Vault Privy <br /> 14❑System-In-Fill , o c✓i✓� �� <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 /> o�OD -15-06) /0,30 � `/y " Feet 7,� Feet <br /> VII. TANK Capacity Site <br /> INFORMATION in gallons G lions Tanks Manufacturer's Name Concrete Con- Steel Fiber <br /> Plastic Appr. <br /> New Existin structed <br /> Tanks Tank <br /> Septic Tank or Holding Tank 11 El n El 0 <br /> Lift Pump Tank/Siphon Chamber ❑ 1:1 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 /> Plumber'sName:(Prin Plumber's Signature:(No Stamps) MP/MPRSWNo.: Business Phone Number: <br /> 1 ,2.2,701 L-711tre-22L" <br /> Plumber's Address(Street,City,State,Zip Code): <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sani Permit Fee (Includes Groundwater Vatessue Issuing a t5 atur tamps) <br /> pp s5 r�argeFee) <br /> pproved ❑OwnerGiven Initial / 7S p v }� <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 a Buildings Division,Owner,Plumber <br />