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Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> Visconsin In accord with[LHR 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 fou <br /> than 8 vnt i x 11 inches in size. <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> Personal information you provide may be used for secondary purposes E]Check I e --oJs bpplication <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number Vnn <br /> V1 <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATI N <br /> Property Owner Name Property Location <br /> --r G r SE1/4 S 1/4,S T yQ ,N,R /s W <br /> Property Owner's Mailing Address Lot Number `� Block Number <br /> !S 4, -o Q )-4v 5 <br /> CitState Zip Coe Phone Number Subdivision Name or CSM Number I1, �D V, <br /> 11. TYPE OF BUILDING: (check one) ❑ State Owned 'tye NearestRoad <br /> 171 ❑ VillagJ A <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms Town or C L"3 av-' 1 <br /> III, BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo O/.;)," g67s—O(c ebb <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. IK New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> _ System _ _ _System ____ _ ___ Tank Only ______ __ Existing System __ ___ ExistlnSystem <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 b45eepage 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 /> Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) p Elevation <br /> 3C Z 3 � /Z. O Feet / Feet <br /> VII. TANK Capacity site <br /> in gallons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- plastic Exper <br /> INFORMATION New Existin f <br /> Gallons Tanks Concrete strutted glass App. <br /> Tanks Tanks <br /> Septic Tan rHoldingTank V 1 1 -7 TO I ( ® E] <br /> Uft Pump Tank/Siphon Chamber Q El El 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's Name-(Print) Plu ber's Signa re: No Stamps) MP/MPRSW No.: Business Phone Number: <br /> I S 6-- <br /> Plumber's Address Street,City,State,Zip Code): <br /> tf S o�K [�✓ <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved tary Permit Fee`l1nul rg ro:dwacer ate ue Issuingg9taSigna (N ps) <br /> A ed E]Owner Given Initial 7S� /surcharge Fee) <br /> Adverse Determination J �/L/ <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.11197) DISTRIBUTION: Original to County,One copy To: safety&Builciings Division,Owner,Plumber <br />