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o <br /> Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> Nvisconsin P O Box 7302 <br /> -'Department of Commerce 1n accord with Comm 83.05,Ws.Adm.Code Madison,WI 53707-7302 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County �, f�� <br /> than 8 12 x 11 inches in size. `7 <br /> • See reverse side for instructions for completing this application State Sanitary PermitNumber <br /> Personal information you provide may be used for secondary purposes ❑check it re3n-7df3ous�ppllcation <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> I. APPLICATION INFORMATION- PLEASE PRINT ALL INF RMATION IN <br /> Prop rt Owner Name Property Location <br /> 1/4 1/4,5 141 T dp ,N, R E(or W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 12,g?- 47- 5r- 24425' <br /> CitState Z' od Phone Number Subdivision Name Sr CSM Number <br /> AulDso4 I• �° Orb (P715. <br /> !S S3 _5of �✓ t,u_ <br /> II. TYPE OF BUILDING: (check one) E] State Owned ircel <br /> Cit !'QgNearest Road <br /> Vll age AKt.��/►� <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms 3 Town OF <br /> 111. BUILDING USE: (If building type is public,check all that apply) TaxNumber(s) <br /> 6ac�-1'acci-la-foo <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 online B,if applicable) <br /> A) 1. ❑ New 2.14Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> SYstem System <br /> ------------------------------------Tank lir_-_______-____ Ext---------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 W)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.) Pro osed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> 45D G 43 4 g . -r �— q�e • Feet Feet <br /> Capacity <br /> VII. TANK In dllon5 Total #Of Prefab. Site Fiber- Exper <br /> INFORMATION g Gallons Tanks Manufacturer's Name concrete Con- Steel glass Plastic App <br /> New Exist in structed <br /> Tanks Tank <br /> Septic Tank or Holding Tank IV00 ( `^� El I El El ❑ 0 <br /> Llft Pump Tank/Siphon Chamber El I ❑ Ej I Q El E] <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:(N St a s) MP/MPRSW No.: Business Phone Number: <br /> c4AAV o wI�JS ..�•wl 2z S�Si /S-946- S-7 <br /> PI ber's Address(Street,Citytate,Zip Code): <br /> O ' <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> OF <br /> Disapproved Sa ary Perm t Fe (includesGroundwaterate ssue Issuing Age gnatur <br /> I (J L J Surcharge Fee) <br /> ved ❑Owner Given Initial <br /> Adverse Determination <br /> X. CONDITIONS OF A /11� <br /> P /REASONS F R ISAPPROVAL:*4) <br /> r <br /> SBD 6398(R.4/99) DISTRIBUTION: Original to County.One copy To: Safety&Buildings Division,Owner.Plumber <br />