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Safety and Buildings Division <br /> �Vi5COn5►n SANITARY PERMIT APPLICATION P o W W.Washington Avenue <br /> 02 <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 Co my <br /> than 8 112 x 11 inches in size. gawgmp� <br /> • See reverse side for instructions for completing this application State Sanitary Perrmtt Number <br /> Personal information you provide may be used for secondary purposes ❑Check in to previous applicarion <br /> [Privacy Law,s. 15.04(1)(m)). State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION <br /> Propert Owner Name Property Location <br /> 1/4 1/4,S T ,N, R 1'5 E(clW <br /> Property Owner's Mailing Addr ss Lot Number Block Number <br /> 3 -S$ <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> M� ( _ v.11 <br /> II. TYPE OF B ?(check one) ❑ State Owned ❑ Nearest Road <br /> ❑ VII age <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms own OF IrJ <br /> III. BUILDIN U E: (if building type is public,check all that apply) Parcel TaxNumber(s)�7► <br /> 1 ❑ Apartment/Condo o 1 925D 0-S-1 <br /> 00 <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 ew 2. E] Replacement 3_ E] Replacementof 4. E] Reconnection of 5_ E] Repair of an <br /> __-_Snteg _ 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)aeepage Bed 21 E]Mound 30 El Specify Type 41 E]Holding Tank <br /> Y <br /> 1 ❑"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 /> Req u red(sq.ft.) Proposed(sq.ft.) (Gals/da /sq.ft.) (Min./inch) q Elevation <br /> 300 0 �- /Zr'2 Feet Feet <br /> Cap&cit <br /> VII. FORMATION Site <br /> i" allons Total #of Manufacturer's Nan* Prefab. Con- Steel Fiber- plastic Exper. <br /> New Existin Gallons Tanks Concrete strutted glass App. <br /> Tank T nks <br /> Septic Tank or Holding Tank ❑ ❑ ❑ ❑ ❑ <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)x Plumber's Signature-(N amps) MP/MPRSW/No: Business Phone Number: <br /> 0 �s 22SZVT,7ty- - K <br /> Plumber's Address(Street,Cit ,State,Zip Code). <br /> IX. COUNTY/DEPART Y <br /> NT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing nt Signature(No Stamps) <br /> A Owner Given Initial roved _4 1—7� (JS urcharge Fee) <br /> pp <br /> Adverse Determination ' <br /> ONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.4/99) DISTRIBUTION: Original to county.One copy To: Safety&Buildings Division,Owner,Plumber <br />