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Safety and Buildings Division <br /> N�!��A SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> isi�onsin P O Box 7 I <br /> Department of Commerce 1n accord with Comm 63.05,Wis.Adm.Code Madison,WI 53707-7302 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less th�k <br /> G f �( 6 / <br /> than 8 vi x 11 inches in size. 7 (D• See reverse side for instructions for completing this application it Number <br /> Personal information you provide may be used for secondary purposes o prevfoupa plicat on[Privacy Law,s. 15.04(1)(m)]. ber <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION <br /> Property Owner Name _ Property Location <br /> e,r- SE1/4,je 1/4,S 3.s T�y ,N, R/L E(or)V <br /> Property Owner's Mailing As Lot Number Block Number <br /> Ro, a <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> Sii`en� u✓ s—YFt7�- t ) <br /> II. TYPEF BUILDING: (check one) C] State Owned illage <br /> " Nearest Road <br /> Public X1 or 2 Family Dwelling-No.of bedrooms WTown OF <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax <br /> iNumber(s) / <br /> 1 ❑ Apartment/Condo 01O 3-73 -5- <br /> 2 <br /> '73S2 ❑ 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. E] Replacement <br /> 3, ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> System System Tank Only EKstyjq S stem --- Existing-------- <br /> 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 E6-Seepage Trench 22❑In-Ground Pressure a 42❑Pit Privy <br /> 43 El Vault Privy <br /> 13❑Seepage Pit <br /> 14❑System-In-Fill 3 N�ci�fi Aar" <br /> VI. ABSORPTION SYSTEM INFORMATION: <br /> t <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/day/sq.ft.) (Min./inch) qs,y Elevation <br /> D O p b 0 1104 � 6 17`le L Fee97 Feet <br /> VII. TANK CapacltY Site <br /> in gallons Total #of Manufacturer's Name Prefab. Con- steel Fiber- Plastic Exper <br /> INFORMATION New Existin Gallons Tanks Concrete strutted glass <br /> /+PP <br /> T nks Tank <br /> Septic Tank or Holding Tank ��s0 asa 0 � El <br /> Lift Pump Tank/Siphon Chamber El 101 <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) <br /> Plumber's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> A�� �H S�d�.+, �'✓� � -74 91 .7Y7 728 <br /> Plumber's Address(Street,City,Stat,Zip Code): <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disa rOVed Sanitary Permit Fee (includesGroundwater at ssue Issuing ge Sign N amps) <br /> ❑ PP surcharge Fee) <br /> iproved ❑Owner Given Initial /�� <br /> Adverse Determinationil <br /> l <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> DISTRIBUTION: Original io County.One copy To: Safety 8 Buildings Division,Owner,Plumber <br /> SBD-6396(R.4/99) --- — <br />