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Safety and Buildings Division <br /> Visconsin SANITARY PERMIT APPLICATION 201 Bow302ngton Avenue <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 <br /> than 8112 x 11 inches in size. 46 ea/t/V 3 77/ <br /> • See reverse side for instructions for completing this application State Sanitarypermit umber <br /> 3� g <br /> Personal information you provide may be used for secondary purposes q17 <br /> ❑Check it revision to previous application <br /> (Privacy Law,s. 15.04(i)(m)]. State Plan I.D.Number/L,--/ <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION <br /> Prop rtyOwner ame Propert citation <br /> iv a s.J 1/a 1/a,S r T. ?cJ ,N, R�G E(o W' <br /> of <br /> PropertyOwner' Mailing dr Lot Number Block Number <br /> CIV t� <br /> City,state Zip Code Phone Number Subdivision Name or CSM Mumber <br /> . TYPE OF BUILDING: (check one) ❑ State Owned E] ity Nearest Road <br /> ❑ vii age <br /> Public EL 1 or 2 Family Dwelling-No.of bedrooms 2 CKown of n•e-G,-1LdQ <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNuumber(s) <br /> 1 ❑ Apartment/Condo 6)`,' -�j -b�-6� <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. R1 New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> -______-stem -___---_System ------------- Tank Only__-_---_____-- Existing System _______- Existing <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 /> 1 1Seepage Bed 21 E]Mound 30 E]Specify Type 41 ❑Holding Tank <br /> 12 Seepage 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/d9/sq.ft.) (Min./inch) Q p Elevation <br /> �Q Q d S J Feet Feet <br /> Capact <br /> VII. FORMATION in allo s Total #of Manufacturer's Name Prefab. Con steel Fiber- Exper. <br /> Gallons Tanks Concrete lass Plastic App <br /> New Existin strutted g <br /> Tanks Tanks " <br /> Septic Tank or Holding Tank QQd QC1c) wOrWeSCicT ❑ ❑ ❑ ❑ a ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ <br /> Vill. 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:(N Stamps) MP/MPRSW No.: Business Phone Number: <br /> L� do �.s�ol v<,.C�..- - C;2__2 7G 9� �� <br /> Plumber's Address(Street,City,State,Zip Code): <br /> .f7,3e_� �= Vii.^ G 11 � �5/� 7.2 <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved S nitary Permit Fee (IndudesG oundwater ate IssuedIssuing Agent slgnatur N m s) <br /> pproved ❑OwnerGiveninitial / /—f J� ��i�r<nergeceet /_ <br /> Adverse Determination / VV <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.4/99) DISTRIBUTION: Original to County,One copy To: Safety&Buildings Division,Owner,Plumber <br />