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~ 1 Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> Vir000nsin In accord with ILHR 83.05,Wis.Adm.Code P O Box 7302 <br /> Department of Commerce Madison,WI 53707-7302 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County <br /> than 8 1/2 x 11 inches in size. 8, <br /> • See reverse side for instructions for completing this application a sanitary Permit Number�y ( , <br /> Personal information you provide may be used for secondary purposes -3503(O / ]J <br /> (Privacy Law,s. 15.04(1)(m)]. ❑Check if revision to previous application 6C, <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION- PLEASE PRINT ALL INF RMATION <br /> Pro erty Owner Name Property Location <br /> 1/4 1/4,5 T N, R E(oI�W <br /> 06 <br /> Pre y O er's MaijUnc ddress141 i_k4. Lot Number Block Number <br /> w <br /> C; ,State _! Zi Code Phone Number Subdivision Na or SM Number <br /> JM4 Ann. le) <br /> 11. TYPE OF BUILDING: (check one) ❑ State Owned ❑ !t Nearest Road <br /> El Public 1 or 2 FamilyDwelling- No.of bedrooms vll age >AGG� <br /> Town OF, <br /> III. BUILDIN USE: (If building type is public,check all that apply) Parcel Tax Number(s) IF Is <br /> 1 ❑ Apartment/Condo b i a- gisSD -Oa- <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreatli _ ity <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. E] Replacement 3. E] Replacementof 4. E] Reconnection of 5 ❑ Repair of an <br /> _-- System ----- --System------------- Tank Only----------- Existing System ExistingSystem <br /> -------- 9 y------------------ -�---- <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 /> 110 Bed 21 ❑Mound 30❑Specify Type 41 ❑Holding Tank <br /> 1 eepage Trench 22 E]In-GroundPressure 42 E]Pit Privy <br /> 1 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.) Propos (sq.ft.) (Gals/da /sq.ft.) Min./inch) Elevation <br /> 3� 3 2-•7 Feet 95 .2:-Feet <br /> VII. TANK Capacuty <br /> INFORMATION in gallons Total #of Manufacturer's Name Prefab. con Fiber- plastic Exper. <br /> New Existing Gallons Tanks concrete steel glass App. <br /> strutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank El ❑ <br /> Lift Pump Tank/Siphon Chamber 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 ber's Name:(Print) Plumber's Signature:(N S s) Tm'P/MPRSWNo.: Business Phone Number: <br /> G('A <br /> - : <br /> PI tier's Add ess Street,City,Sta Zip Code): <br /> IX. COUNTY!DEPARTMEI Y <br /> ❑Disapproved Sanitary Permit Fee (includes6roundwater ate IssuedIssuing Ag t Sign ture( St PS) <br /> pproved E]Owner Given Initial urcharge Fee) <br /> Adverse Determination 566 ��3 <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398 IRA 1/97) - DISTRIBUTION: Original to County.One copy To: Safety a Buildings Division,Owner,Plumber <br />