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Safety and Buildings ivision <br /> SANITARY PERMIT APPLICATION 201 E.Washington Ave. <br /> Vis' ponsin In accord with ILHR 83 05,Wis.Adm.Code P.O.Box 7969 <br /> Department of Commerce Madison,WI 53707-7969 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County, <br /> than 8 112 x 11 inches in size. <br /> • See reverse side for instructions for completing this application state Sanitary Per iitt(Number <br /> The information you provide may be used by other government agency programs E]Check if revision previous application <br /> [Privacy Law,s. 15.04(1)(m)]. <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Name l Property Location / <br /> r i e/cY <br /> 4.,?n_ 4 /L&1/4'S __7 /�-7 T N• R E(or W <br /> Property Owner's Mailing Address / Lot Number Block Number <br /> City State Zip Code Phone Number Subdivision Name or CSM Number <br /> u,- 3 ( V?6/ <br /> Il. TYPE F ILDING: (check one) ❑ State Owned Elit� r Nearest Road <br /> Public 1 or 2 Family Dwelling-No-of bedrooms 9 own of <br /> Ill. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo <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. E3 Replacement of 4. (] Reconnection of 5. E] Repair of an <br /> ___System ____ �ystem _ ------ 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 ELSeepage 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 S. Perc. Rate 6. System Elev. 7. Final Grade <br /> Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> Feet7.0' Feet <br /> TANK Ca aclt <br /> VII. INFORMATION in gallons Total #of Manufacturer's Name prefab. Site Con- Steel glass plastic Exper Existin Gallons Tanks concrete structed glass App- <br /> New <br /> Tanks �y �,/_ <br /> Septic Tank or Holding Tank p OG b�U +�iT� ❑ ❑ ❑ ❑ ❑ <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.( Stam s) MP/MPRSWNo.: Business Phone Number: <br /> Plumber's Ac dress(Street,City,State,Zip Code): <br /> d � I/ --S I-/`lt' f e--'.7 `J -57 Z <br /> IX. COUNTY/DEPARTMENT USE ONLY / <br /> ❑Disapproved Sanitary Permit Fee (includes Groundwater ate Issued Issui gent Signature(No Stamps) <br /> Approved pp ❑Owner Given Initial Surcharge Fee) <br /> Adverse Determination / f <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.11/96) DISTRIBUTION: Original to County.One copy To: Safety 8 Buildings Division,Owner,Plumber <br />