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fety <br /> SANITARY PERMIT APPLICATION sad Buildings Division <br /> Visconsin <br /> 201 W.Washington Avenue <br /> P O Box 7302 <br /> Department of Commerce In accord with Comm 83.05,Wis.Adm.Code Madison,WI 53707-7302 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less Cou 3 30 <br /> than 8112 x 11 inches in size. y yt.e <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> 36a 7/ l <br /> Personal information you provide may be used for secondary purposes ❑Check if revision to previous application W <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number„ d <br /> I. APPLICATION INFORMATION- PLEASE PRINT ALL INF RMATION I <br /> Pro ertyOwnerNamProperty Location � ��� <br /> II-2vim. �1 lu(4/11/4 SE- 1/4,S a. T 3 ,N, R ( L4`aFO <br /> Property Owner's Mal ng Add"ess Lot Number Block Number <br /> L o SLOie r. <br /> Cit State Zip Code Phone Number Subdivision Name or CSM Number <br /> 11. TYPE OF <br /> BUILDING: (check one) E] State Owned 0 I-Ity 1 ' Nearest Ro d <br /> Public 1 or 2 FamilyDwelling �-No.of bedrooms , Town OF 1 e 4 m&a4� ( -P 1pZ=, <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax <br /> /Number(s) 0-r,1 F1 Apartment/Condo d7© 3 ��-1 O� 0 %_1C) <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. U Replacement 3_ ❑ Replacement of 4. ❑ Reconnection of 5_ ❑ Repair of an <br /> System System Tank Only Existing System Existing 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 /> 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. 1 7. Final Grade <br /> Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) 7 Elevation <br /> I) 1 J`L `i',3 a2 , G/ 7, Feet , 3 Feet <br /> TANKCa acit <br /> VII Site <br /> INFORMATION in gallons Total #of Manufacturer's Name Prefab. Con- steel Fiber- Plastic Exper. <br /> New Existin Gallons Tanks concrete strutted glass App- <br /> New <br /> Tanks Tanks <br /> eptic T or Holding Tank s"b I I t.Ser (r�r <br /> ❑ ❑ ❑ ❑ ❑ <br /> LIR Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ 1 ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibi 'ty for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name:(Print) Plu ber's Signatu e: Stamps) MP/MPRSW No.: Business Phone Number: <br /> �oer r Zzrs2z 7/S. �Co�- cam <br /> Plumber's_Vd_(Strclivi�y,St te,Zip 1 / � �t 6 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Y// S <br /> ❑Disapproved Sanitar Permit Fee (include'Groundwater ate issuedIssuing a Sign ure ps) <br /> Noved harge ree) <br /> ❑Owner Given Initial / 75 (sO t�jd..oi7 <br /> VV Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.4/99) DISTRIBUTION: Original to County,One<opy To: Safety 8 Buildings Division,Owner,Plumber <br />