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Safety and Buildings Division' <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> onsin P O Box 7302 <br /> Commerce In accord with Comm 83.05,Wis.Adm.Code Madison,WI 53707-7302 <br /> _ .nplete plans(to the county copy only)for the system,on paper not less County , t <br /> than 81/2 x-11 inches in size. j9 tt V ill-e <br /> • See reverse side for instructions for completing this application State Sanitary Perm it <br /> 77mberJJy/�, <br /> Personal information you provide may be used for secondary purposes El Check <br /> ev n to previous'appli�ion <br /> [Privacy Law,S. 15.04(1)(m)). State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION <br /> Property Owns�j(j Name Property Location <br /> YN�r)Gk- va M w X11 N9-1/4 Sw 1/4,S 7 T fto ,N, 1110' E(or)o <br /> Block Nu. Lbe�j <br /> Property Owner's�aM.aili g Address d Lot Number rr <br /> 3J 3 9 Gr1Yy1Cs five• N+ �i,u .I Let– <br /> Property <br /> Ot <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> ao6 /� dalesr4AI. I( ),S'a,q-g7rj GSM U, pis 6U <br /> 11. E OF BUILDING: (check one) ❑ State Owned ❑ It� Nearest Road 0p <br /> Public 1 or 2 FamilyDwelling- No.of bedrooms —1 Town OF J�So 5mil"-n .ae J0 6• <br /> 111. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo v ' <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. M 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 /> 11 N 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 /> �r0 Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> J 9400 900 -� �' 4 Feet 41 . Q Feet <br /> Capacit <br /> VII. INFORMATION in allons Total #of Manufacturer's Name Prefab. Con steel Fiber- Plastic Exper. <br /> New Existin Gallons Tanks Concrete strutted glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank 600 — /000 ® ❑ ❑ ❑ ❑ ❑ <br /> 14 <br /> Lift PumpTank/Siphon Chamber 400 600 © ❑ ❑ ❑ ❑ ❑ <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) Plumber's Signature(No tamps) MP/MPRSW No.: Business Phone Number: <br /> k^44 Z.�38 7�s-S�-q/s7 <br /> lumber's Address(Street,City,State,Zip CVucj. <br /> ).7766 /fw 35' W-c-bStY,- <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved nitaryPermit Fee (includes Groundwater ate IssuedIssiin ents n S amps) <br /> pproved ❑ Surcharge fee) <br /> Owner Given Initialj� q <br /> Adverse Determination 5-" `� r2< <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.4/99) DISTRIBUTION: Original to County,One copy To: Safety a Buildings Division.Owner,Plumber <br />