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Safety and Bu ildings Divisidn <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> Aloconsin' P o Box 7302 <br /> Department o, 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 Co my �, a�aa3 <br /> than 8 1/2 x 11 inches in size. <br /> • See reverse side for instructions for completing this application State SanitaryPermitumble/pr <br /> Personal information you provide may be used for secondary purposes ❑Check it revision t6 previous spplic tion �c <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan;,.D_ b <br /> 1. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION <br /> Property Owner Name Propert Location <br /> 1plifrBAR �1/4 1/4,S 34 T41 ,N, R l{o E(o <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 2I -.VW.SA 329 <br /> . <br /> Cily,State Z&Code (hone N bete Subdivision ame or C�_Number <br /> M �+� '1 <br /> TYPE BUILDING: (check one) ❑ State Owned ❑ city I Nearest Road <br /> ❑ VII age <br /> El Public 1 or 2 FamilyDwelling-No.of bedrooms Town of 51�IS L <br /> III. BUILDING USE: (If building type is public,check all thatapply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo a 037, 5334 04 470 <br /> 2 ❑ Assembly Hall 6 ❑ Medica[ 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 2.1vteplacement 3_ ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> System <br /> ------ ------------------------------------------------------------------- Tank Only stem <br /> ------------ -_-__ __---_ Existing Sy --_______Existlnt�------- <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 epage Trench 22❑In-Ground Pressure 42❑Pit Privy <br /> 3❑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 /> Req it disq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation (, <br /> 3 , '�� � �eet .Feet <br /> Capacity <br /> VII FORMATION in gallons Total #of Manufacturer's Name Prefab. Con- Steel site Fiber- Plastic App. <br /> New Existin Gallons Tanks Concrete strutted glass App. <br /> TanksTanks <br /> Septic Tank or Holding Tank <br /> Lift Pump Tank/Siphon Chamber, Iry ❑ ❑ ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plum er"s Name:(Pant) Plum 's Signatur No amps) TM;P/MPRSW No.: Business Phone Number: <br /> 258 s- - <br /> Plu ber's Address(Street,City,State,Zip C ): <br /> o <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanit y Permit Fee (Includes Groundwater ate IssuedIssuing A Signat e( S ps) <br /> A roved Owner Given Initial Surc ge Feet <br /> p ❑Adverse Det Initi -7— <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.4199) DISTRIBUTION: Original to County.One copy To: Safety&Buildings Division,Owner.Plumber <br />