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Safety and uildings Di ision <br /> onsin SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> P O Box 7302 <br /> Depart 1t 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 �',� <br /> than 8112 x 11 inches in size. <br /> • See reverse side for instructions for completing this application STate Sanitary Per jtNit Nuu)mber <br /> Personal information you provide may be used for secondary purposes ❑Check if rcevi��pr—e�l6us application <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATI N <br /> PropeyV Owner Name Property Location <br /> 1/4 1/4, 7 N, R E(or <br /> Prope y Owner's M fling Address 4— B <br /> Number r <br /> 5 8o �l 2+°�T;9 UID - L. <br /> City,State Zip C de P one Numberdivjilgn Name qr CSM Number <br /> PLS_ PIN S n'� i f <br /> 11. TYPEILDING: (check one) ❑ State Owned it Nearest Road <br /> illage A v, yl� r �60� <br /> Public 1 or 2 FamilyDwelling-No.of bedroomsown OF FY7 P <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo I <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_.gr Replacement 3, ❑ Replacement of 4. ❑ Reconnection of 5, ❑ Repair of an <br /> System 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 ❑Seepage Bed 21 ❑Mound 30❑Specify Type 41 ❑Holding Tank <br /> 12'RSeepage 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.) Proposed(sq.ft.) (Gals/ ay/sq.ft.) (Minch) �$, Elevation <br /> Feet Feet <br /> aclt <br /> VII. TANK in Ca allons Total #of Prefab. Site Fiber- Exper <br /> INFORMATION g Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App <br /> New lExisting structed <br /> Tanksl Tanks <br /> Septic Tank or Holding Tank ❑ 0 <br /> Lift Pump Tank/Siphon Chamber 6 El ❑ <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 Signatur (N tamps) MP/MPRSW No.: Business Phone Number: <br /> PO ZZ SCSI 171r- (v6- CS' <br /> Plu tier's A�e}s Streoet,Cit ,, tate,Zip Code): � �� <br /> 7 /vft, <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (includes Groundwater ate IssuedIssuing Age t Si nature(No St <br /> roved ❑ 1 7� surcharge Pee) <br /> Owner Given Initial / C7(J <br /> Adverse Determination <br /> X. CONDITI//ONS OF APPROVA /R/EASONS FOR DISAPPROVAL:4eLcj/] <br /> J <br /> SBD-6398(R.4/99) DISTRIBUTION: Original to County.One copy To: Safety 8 Buildings Division,Owner,Plumber <br />