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` Safety and uildings ivision <br /> Vlsi6onsin <br /> SANITARY PERMIT APPLICATION 201 w.Washington Avenue <br /> P O Box 7302 <br /> Dbpartment of Commerce In accord with[LHR 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 Count <br /> than 8 1/2 x 11 inches in size. ell <br /> • See reverse side for instructions for completing this application State Sanitar Pelrm�it NumbG/e�r <br /> Personal information you Provide may be used for secondary purposes E]Check it r on o�r�evious app kation ] <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> 1. APPLICATION INFORMATION- PLEASE PRINT ALL INF RMATIONN <br /> Property Owner Name Property Location � <br /> 4 1/4 1/4,S e2 7r T V6 ,N, R/ .. E(or) <br /> n <br /> Property O ner's Mailing AddrresssLot Number Blodred4�l►ber d <br /> 375" l e L) c/' G .L , <br /> CState Zip Code Phone Number Subdwes+e, n�lame or CSM Nyfnber <br /> itX-eSS'e•/' Gtl O oF <br /> 11. P BUILDING: (check one) ❑ State Owned o IVillty Nearest Road <br /> a ❑ age Kso <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms Town of <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo /L _O <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/Mote[ 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 Nye2. ❑ Replacement 3, ❑ Replacement of 4. ❑ Reconnection of 5_ ❑ Repair of an <br /> '~Sstem System -- Tank Only --_-- _- _ Existing System --_- __ ExlstlnqSystem <br /> ------------------------------------- <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 Meepage 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 13. Absorp.Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade <br /> Required(sq.ft.) Prop,psed(sq.ft.) (Galstday/sq.ft.) (Min./inch) q Elevation <br /> �© Q 00 6 0('j i S� /-� SFeet 9B: / Feet <br /> VII. TANK Capacity Site <br /> INFORMATION in gallons Total <br /> Tanks Manufacturer's Name Concrete Con- Steel Fiber Plastic APpr <br /> New Existin structed <br /> Tank Tanks 4r7 S ��f ❑ ❑ ❑ ❑ ❑ <br /> Septic Tank or Holding Tank �� <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ 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)DPlumber's Signature:MStamps) MP/MPRSW No.: Business Phone Number: <br /> Plumber's Address(Street,City,State,Zip Code): <br /> ,CSO Ar� S 1 Y St/` C ti <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (includes Groundwater ate ssue Issuing A n gnat r (No a s) <br /> 7 Fee) <br /> Approved ❑Owner Given Initial ���.. <br /> D Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DI APPROVAL: <br /> DISTRIBUTION: Original to County,One copy To: Safety a Buildings Division,Owner,Plumber <br /> SBD-6398(R.11/97) — <br />