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PUTErVSC Safety and Buildings Division <br /> Visconsin SANITARY PERMITAPPLIC�►W AIWUashingtonAvenue <br /> P�b x 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 Co <br /> than 8112 x 11 inches in size. 5 �a 3�3p <br /> • See reverse side for instructions for completing this application St a Sanitary Permit Number <br /> Personal information you provide may be used for secondary f04) ��� f� <br /> y p y ry purposes � � � ❑Check 1 revision o previous appli anon <br /> [Privacy Law,s. 15.04(t)(m)]. o 3�I State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION tfW,1 <br /> Propertner Name Property Location W <br /> 1/4 1/4,S (Z T N, R E(or U <br /> Property Owner' Mailing Address Lot m er Block Number (�I <br /> Cit ,Stat '' `` Zi Code Phone Number Sub vision Name or CSM Number v <br /> WI G ( 5 ) <br /> II. TYPE OF BUILDING: (check one) ❑ Statb Owned city Nearest Road <br /> village <br /> Public 1 or 2 FamilyDwelling �IT-No.of bedrooms own OF R— <br /> III. BUILDING USE: (If building type is public,check allthatapply) Parcel TaxNumber(s)�f <br /> 1 ❑ Apartment/Condo 01Z_ _- <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. rNew 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5_ ❑ 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 /> 11Seepage Bed 21 E3 Mound 30 E]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 S. Perc. Rate 6. System Elev.d 7. Final Grade <br /> 31,00V $Required(sq.ft.) Proposesq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> Feet 3 Feet <br /> Ca aclt <br /> VII FORMATION in altos Total #of Prefab. Site Fiber- Exper. <br /> g Gallons Tanks Manufacturer's Name Concrete con- steel glass Plastic App <br /> New Existin strutted <br /> Tank Tanks <br /> Septic Tank or Holding Tank 1 " ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ I ❑ I ❑ ❑ <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) LL Plum fie 's Sig natu -;(N tamps) MP/MPRSW No.: <br /> Business Phone Number: <br /> r\ 1 Z2 500sol <br /> PI m ber's Address(Street,Ci y,State,Zip Code) <br /> 7 6o L,l <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sa Permit Fee (IndudesG,oundwater Date Issued Issuing Age <br /> roved �� rc rge Fee) <br /> pp ❑Adverse Determination <br /> al 16-13'2 <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.4/99) DISTRIBUTION: Original to County,One copy To: Satety&Buildings Division,Owner,Plumber <br />