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0 r 1. fety and Buildings Division <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> '` 6consin In accord with ILHR 83.05,Wis.Adm.Code P O Box 7302 <br /> Department of Commerce Madison,WI 53707-7302 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less c at$ I <br /> than 81/2 x 11 inches in size- n <br /> • See reverse side for instructions for completing this application State Sanitary Permit Num er <br /> 3-;)-S_-�>Sv <br /> Personal information you provide may be used for secondary purposes ❑Check if revision to previous application r <br /> [Privacy Law,s. 15.04(1)(m)1. State Plan I.D.Number <br /> I. APPLICATION INFORMATION- PLEASE PRINT ALL INF RMATION <br /> Property er Na7e Property Location Q <br /> 1/4 1/4,S/ T ,57 ,N,R /tJ X(or)W <br /> Propert Owner's Ma' ' g Add es Lot Number Block Number <br /> WwnIgI <br /> �- <br /> Cit ,State Zip Code Phoneum er / Subdivision Na neorCS Nuber <br /> E OF BUILDING: (check one) ❑ State Owned fibs Cit� Nearest Road <br /> ❑ Vil age ``,^, <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms 7o <br /> Town OF C� /1 f <br /> III. BUILDING USE: (If building type is public,check all that apply) arcel lax Number(s) <br /> 1 ❑ Apartment/Condo IC&V-/SO/-C?q 300 <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.n- Replacement 3_ E] Replacement of 4. EDReconnection of S. [:] Repair of an <br /> 5 stem -_ --System -- Tank Only - System _--_ _ E----�----- <br /> ------- --- System <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 ❑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 /> )4❑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) n/y Elevation <br /> Feet Feet <br /> VII. TANK CacutIn gallons Total #Of Prefab. Site Fiber- Exper. <br /> New Existingstrutted <br /> INFORMATION Gallons Tanks Manufacturer's Name Concrete con- steel glass Plastic App <br /> T nks Tanks <br /> Septic Tank or Holding Tank Q 0 510JAI ❑ 1 0 0 <br /> Lift Pump Tank/Siphon Chamber 45W 1 S�0 ❑ E] 1 <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 Sign ture, o Stamp / MP/MPRSW No.: Business Phone Number: <br /> o ,,., u3Ca/ C�15 <br /> Plu ber'sA dress(Street, ity,State, ipCode), <br /> OrZY. <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapprove( Sanitary Permit Fee (Includes <br /> Groundwater a e ssuing Ag nt Signa ure( mps) <br /> harge Fee) <br /> Approved <br /> !�_N-08 <br /> Adverse Determination 6 1 /O <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.11/97) DISTRIBUTION: Original to County.One copy To: Safety&Buildings Division,Owner,Plumber <br />