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Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION 201 E.Washington Ave. <br /> Visconsin In accord with ILHR 83 05,Wis.Adm.Code P.O.Box 7969 <br /> Department of Commerce Madison,WI 53707-7969 <br /> • Attalch complete plans(to the county copy only)for the system,on paper not less County <br /> than 8 112 x 11 inches in size. e C&I^ n <br /> • See reverse side for instructions for completing this application state Sanitary Permit Number <br /> / er// <br /> The information you provide may be used by other government agency programs ❑Check it revision to preJi6Gs applicati n <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Numbed/� <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION I <br /> Property Owner Name Propperty LocationS T �} ,N, R ( E(or) <br /> D - 1 tc stn +n SE S� 4 r <br /> Property Owner's Mailin Address Lot Number Block Number <br /> 13-7 -7 Co. /�! P <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> II. TYPE F B I DING: (check one) ❑ State Owned ❑ ity Nearest Road <br /> 171 Public 1 or 2 FamilywellingD -No.of bedrooms �— ° Town OF 5cv tss Inst Road <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo 3a- SaO� <br /> 2 ❑ Assembly Hal[ 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. I&New 2. ❑ 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 JZ Seepage Bed 21 ❑Mound 30❑Specify Type 41 ❑Holding Tank <br /> 1 ❑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) EI vation <br /> 300 q -z �.- q5. 1 Feet 7.(o Feet <br /> TANK Capact <br /> VII INFORMATION A <br /> in allons Total #of Manufacturer's Name Prefab. Con- Steel Site Fiber- Plastic per_ <br /> New ExistingGallons Tanks concrete strutted glass App. <br /> Tanksi Tanks <br /> Septic Tank or Holding Tank C ❑ ❑ ❑ ❑ ❑ <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:(Print) Plumber's Signature,(No tamps) MP/MPRSW No.: F711,5-966- <br /> ess Phone Number: <br /> viromw1 d Zz SSI qJ0 <br /> P umber's Ac dress( treet,City, tate,Zip Code): <br /> E13 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (Includes Groundwater ate IssuedIssuing Agent ignat re(N St )s) <br /> roved 1 �� gereet /�p��9 <br /> p ❑Owner Given Initial <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FORDISAPPROVAL: <br /> SBD-6398(R.11/96) DISTRIBUTION: Original to County.One copy To:Safety 8 Buildings Division,Owner,Plumber <br />