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Safety and Buildings Division <br /> Visconsin <br /> SANITARY PERMIT APPLICATION 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 County a <br /> than 8112 x 11 inches in size. <br /> • See reverse side for instructions for completing this application State Sanitary Permit NumbeerrS <br /> w 35 <br /> Personal information you provide may be used for secondary purposes ❑cneca tFrevision previoDus application <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 Loc ti S 11T ,N, R 15 E(O <br /> 19 <br /> f93T <br /> Propert Own er Mailing Address [ Lot Number Block Number <br /> City,StateZ J Z' 0 ' <br /> Phone Number Subdivision Name or CSM Number <br /> II. TYPEILD G: (check one) ❑ State Owned ❑ it •Nearest Road <br /> p Village �. ld. � <br /> Public 1 or 2 Family Dwelling-No.of bedroomsIsn'rown OF <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo ofC-;�_%7503-0)OO <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. XNew 2. ❑ Replacement 3_ ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> ___System --------Syrstem ------------- 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 ❑Seepage Bed 21 ❑Mound 30❑Specify Type 41 ❑Holding Tank <br /> 123KSeepage 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 /> 2,�.� Required sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> 1-54✓"� 75' � Feet $.S Feet <br /> VII. TANK Capacity Site <br /> INFORMATION in gallons Gallons Tanks Manufacturer's Name Concrete Con- Steel Fiber-ass Plastic Appr <br /> New Existin strutted <br /> Tanksl Tanks <br /> Septic Tank or Holding Tank Soo OCCO � <br /> Lift Pump Tank/Siphon Chamber I I El El Q Ej11 <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: NoS mps) NMP/MPRSWNo.: 13Busin�es,Phone Number: <br /> 1c,+}Aev 51 <br /> Plumber's Address(Street, ity,State,Zip Code): <br /> rr 1- 3 <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (Includes Groundwater a7e;ss Issuing ge Surcharge Pee)�4pproved ❑Owner Given Initial e Q® 7Qf� <br /> �L= Adverse Determination J • <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-8398(R.4/99) DISTRIBUTION: Original to County.One copy To: Safety a Buildings Division,Owner,plumber <br />