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/ Safepan Buildings Division <br /> Aa•A <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> ��� ..,accora wnn���sn aa.os,w'n.sadm.Gvae P 0 BIA T3N2 <br /> oer, rtment of commerce 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. C� Lee 02A Ji eh',232,26, <br /> • See reverse side for instructions for completing this application statuary, Permit Number <br /> Personal information you provide may be used for secondary purposes l ❑Check it revision to previous application <br /> (Privacy Law,s. 15.04(1)(m)]. NW State Plan I.D.Number <br /> I. APPLICATION INFORMATION- PLEASE PRINT ALL INF RMATION <br /> Property Owner Name Property Loc tion <br /> QG '(,J1/4 ,(J(,t�i/4,S TYo ,N,R/�E(or <br /> Property Owner's ailing Address , / Lot Number Block Number <br /> �0i V <br /> C y,State Zip Code Phone Number Subdivision Name or CSM Number <br /> 11. PE IN : (check one) ❑ State Owned ❑ Ity Nearest Road <br /> ❑ Village <br /> Public 1 or 2 Family Dwelling-No.of bedrooms Town OF f7� C G. <br /> 111. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) (, <br /> 1 [-] Apartment/Condo Ua0- g3lq- bl- <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. ❑ Replacement 3. E] Replacementof 4. E] Reconnection of 5. E] Repair of an <br /> ---�_"_`-5ystem _____-_-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 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 /> Aw Required(sq.ft.) Proposed(sq.ft.) (Gal y/sq_I (Min./inch) Elevation <br /> � �, , 3 -'9 Feet Feet <br /> Ca act <br /> VII. NFNORMATION in gallo s Total #of Manufacturer's Name Prefab. CoSitn Steel Fiber- plastic Exper. <br /> New Existin Gallons Tanks concrete strutted glass App. <br /> Tanks I Tanks <br /> Septic Tank or Wel�Fank El El El11 11 <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 Stamps) MP/MPRSWNo.: Business Phone Number: <br /> Plumbe 's Address(Street,City,State,Zip Code): <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> E]Disapproved Sanitary Permit Fee (includes Groundwater atessue Issu gentSignatur OStamps) <br /> Approved E] .$175, <br /> surcharge Fee) <br /> Owner Given Initial 1 7S,, Q p <br /> Adverse Determination / IP <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398 IRA 1/97) DISTRIBUTION: Original to County.One<opy To: Safety&Buildings Division.Owner,Plumber <br />