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1 <br /> Safety and uil ngs DI on <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> N*Isc�nsin P o Box 73oz <br /> In accord with ILHR 83.05,Wis-Adm.Code Madison,WI 53707-7302 <br /> Department of Commerce <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County r X/---3 <br /> than 8 112 x 11 inches in size. <br /> State Sanitary Permit Number <br /> • See reverse side for instructions for completing this application _ 2, � <br /> Personal information you provide may be used for secondary purposes ❑Check it re3n pr vlous apps tlon41 <br /> [Privacy law,s. 15.04(1)(m))- State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEA E PRINT ALL IMATION <br /> Property Owner Name Property Locatio <br /> Sr' M4 .3uJ 3 T cf/ N,R /5—E(Ora— <br /> Property//,Owner's Mailing Address Lot Number Block Number <br /> l0 7(0L / . A/9'2 6, k/9 <br /> ET <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> W- 1 5YB3CD I( /-M— S- >44eA=,5 <br /> II. TYPE OF BUILDING: (check one) ❑ State OwnedItyy Nearest Road <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms �_ <br /> Vowan OF Sun-s <br /> Ill, BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <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 on line B,if applicable) <br /> A) 1. New 2. Replacement 3_ Replacement of 4. [:] Reconnection of 5_ E] Repair of an <br /> � E] E]ystem _ System Tank On <br /> __ _ _ _ l�r______________ E <br /> . xistiSystem ng Syse __ 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 eepage Bed 21 ❑Mound 30❑Specify Type 41 ❑Holding Tank <br /> 12❑ eepage 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 /> Regi sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) 4 Elevation <br /> A);4- L g/'V Feet Z®0�� Feet <br /> VII. TANK Capacity Site <br /> in gallons Total #of Manufacturer's Name Prefab. con- steel Fiber- Plastic Exper <br /> INFORMATION New Existin Gallons Tanks Concrete strutted glass App. <br /> Tanks Tanks _ <br /> all Q El El <br /> Septic Tank or Holding Tank SQ 7sv <br /> Lift Pump Tank/Siphon Chamber D ❑ 0 <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plu is Name:(Print) Plu atur :(yo�s) MP/MPRSW No.: Bu mess Phone Number: <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 5 Srswy�,r 'e-0 31— <br /> IX' <br /> IXCOUNTY/DEPARTMENT USE ONLY <br /> Disapproved Saf <br /> aryPermit Fee (includes GrUundwater ate ssue Issuing a Si ure(N a ps) <br /> ❑ pp Surcharge Fee) <br /> Approved ❑Owner Given Initial l�]S r L)Z <br /> Adverse Determination / 1 �C./ <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 />