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Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> *aconinIn 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 81/2 x 11 inches in size. (� 01 <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 ❑Check it revision to previous application <br /> [Privacy Law,s. 15.04(1)(m)]. �._ <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION <br /> Property Owner N me Property Location15 1S T G ,N, R S E(Or&> <br /> LgAIRVE <br /> Property Owner's M 'lin Address Lot Number Block Number <br /> (hN.G. �$O <br /> y,State •Zip Code Phone Number Subdivision Name or CSM Number <br /> 11. TYPE OF BUILDING: (check one) ❑ State Owned 1. y st Road <br /> Public 1 or 2 FamilyDwelling � Ne re <br /> -No.of bedrooms <br /> _ Tillage . WA <br /> III. BUILDING USE: (If building type is public,check al I that apply) arcelTax Number(s) <br /> 1 C] Apartment/Condo Otz—9 W Q(O—Coo <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Ho1 a 10 tut or Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 1 staurant/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. XNew 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5_ ❑ Repair of an <br /> System ________System _____________ Tank Only______________ Existing System _________ExistingSyrstem <br /> B) 11A 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 /> 11eepage 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 /> Requ're (sq.ft.) Prop sed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) I Elevation <br /> 3. 0 Feet ,s- Feet <br /> Ca aut <br /> VII. TANK in gal l0 5 Total #Of Prefab. Site Fiber- plastic Exper. <br /> INFORMATION Gallons Tanks Manufacturer's Name concrete CO" Steel glass App. <br /> New Existin structed <br /> Tanks Tanks <br /> Septic Tank or Holding Tank ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber _�+ ❑ ❑ ❑ I ❑ I ❑ ❑ <br /> Vlll. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> PI ber's Name:(Print) Plumber's Signature: No ps) MP/MPRSW No.: Business Phone Number: <br /> t <br /> umber's Address(Street, <br /> treet,Cit ,State,Zip Code): <br /> 2 O W <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (lndudesiSm dwater ate IssuedIssuing a Signatur tamps) <br /> #Ap roved 6 Surcharge Fee) <br /> CC// p ❑Owner Given Initial <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.11/97) DISTRIBUTION: Original to County.One copy To: Safety&Buildings Division,Owner,Plumber <br />