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Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> Asconsin P o Box 7302 <br /> Department of Commerce In accord with Comm 83.05,Wis.Adm.Code Madison,WI 53707-7302 <br /> • Attacn complete plans(to the county copy only)for the system,on paper not less County <br /> ig <br /> than 1 1/2 x 11 inches in size. <br /> S ate Sanitary erit Numbp�r <br /> • See reverse side for instructions for completing this application <br /> Personal information you provide may be used for secondary purposes ❑Check it revision to previous application <br /> (Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> I. APP5, <br /> LI ATI N INFORMATION - PLEASE PRINT ALL IN RMATI N <br /> Prope Owner Name Prope y Location <br /> Eva tra,S � T IN, R '( E(or <br /> 4ropejOw6neAddress Lot Number Block Number <br /> Zip Code P ne Number Subdivisi Nameor CSM Number <br /> ( t5 7AZW, I G: (check one) ❑ State Owned !t� Nearest Road <br /> ❑ VII age <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms Z own OF D- <br /> III, BUILDING USE: (Ifbuilding type is public,check all thatapply) <br /> Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo S4 441-1 04 5M <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 ❑ 11 Restaurant/Bar/Dining <br /> Merchandise: Sales/ ❑ <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 /> New 2. ❑ Replacement 3_ E] Replacementof 4. ❑ Reconnection of 5_ E3Repair of an <br /> A) 1. 5 stem System ------------- Tank Only-------------- Existing System ---------Exlsting 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 /> 11Seepage Bed 21 [:]Mound 30 C]Specify Type 41 [1 Holding Tank <br /> 22❑In-Ground Pressure 42❑Pit Privy <br /> 124 Seepage Trench <br /> 43❑Vault Privy <br /> 13❑Seepage Pit <br /> 14❑System-In-Fill <br /> VI. ABSORPTION SYSTEM INFORMATION: <br /> e <br /> 1. Gallons Pr Day 2. Absorp.Area 3. Absorp.Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Fin i l <br /> 94 <br /> - rade <br /> Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) e,t G Feet . � Feet <br /> vaon <br /> e <br /> VII. TANK Capacity Total #of Site Fiber- Exper <br /> in gallons Manufacturer's Name Prefab. Con- Steel I Plastic <br /> INFORMATION New Existin Gallons Tanks Concrete strutted glass APP <br /> Tanks Tanks <br /> Septic Tank or Holding Tank ❑ ❑ ❑ ❑ <br /> El 0 11 <br /> Lift Pump Tank/Siphon Chamber <br /> V111. 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 ( tamps) MP/MPRSW No: Business Phone Number: <br /> P tuber's Address Street, ity,State,Zip Code) <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanit ry Permit Fee (IncludesGroundwater ate slueTlssuingAgSignature( S ps) <br /> f Surcharge Fee) <br /> ❑ )� <br /> oved Owner Given I <br /> prnitial -7 t/�� OCDJI{/J <br /> Adverse Determination ` <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> DISTRIBUTION: Original to County.One copy To: Safety&Buildings Division,Owner,plumber <br /> SBD-6398(R.4/99) <br />