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Safety and Buildings Division <br /> Ifi` 500115%DSANInITARY PERMIT APPLICATION 201 E.Washington Ave. <br /> accord with ILHR 83.05,Wis.Adm.Code P.O.Box 7969 <br /> Department of Commerce Madison,WI 53707-7969 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less Count <br /> than 8 1/2 x 11 inches in size. SCJ N/'itJ e.. <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> The information you provide may be used by other government agency programs ❑Check itrelfsidn tevious application <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> I. APPLICATION INFORMATION- PLEASE PRINT ALL INF RMATI N ------- '� <br /> Property Ovyner Name Property Location .0� <br /> ,6 f/,4.J hod 4-1,_� GJ t/4��= 1/4,S 30 T o N R/� E(or W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> Cg*t Code Phone Number Subdivision Name or CSM Number <br /> II. TYPE OF BUILDING: (check one) E] State Village State Owned E]E] <br /> Road �l <br /> i/ <br /> Public 1 or 2 Family Dwelling- No.of bedrooms —3 Town of <br /> III. BUILDINGUSE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo O Yo YS30 v.;? �aU <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. ❑ New 2. Replacement 3_ ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> System System _______ Tank Only ____________ Existing System----------ExistingSystem <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 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 /> V-5— Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> 7 O i y C, Y� , Feet `�f. 3 Feet <br /> TANK Ca aclt <br /> VII. INFORMATION in allo s Total #of Prefab. Site Fiber- Exper. <br /> g Gallons Tanks Manufacturer's Name Concrete ruct steel glass Plastic App <br /> New Existin strutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank BQU lee v f /1Jaf[.i e s o d ❑ ❑ I ❑ ❑ 1 ® ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ <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:(Pri ) Plumber's Signature:(No Stamps) MP/MPRSWNo.: Business Phone Number: <br /> Plumber's Ar dress(Street,City,State,,Zip Code): _ <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (includes Groundwater rtelssuedIssuingA entSignatu e(NoS s) <br /> r<harge Fee)proved ❑Owner Given Initial [c1 <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR IS PPROVAL: <br /> SBD-6398(R.11/96) DISTRIBUTION: Original to County.One copy To: Safety&Buildings Division,Owner,Plumber <br />