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Safety an it mgs Divisio <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> Visconsin P O Box 7302 <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 3�� <br /> than 8 12 x 11 inches in size- <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> 3S 3a� / <br /> Personal information you provide may be used for secondary purposes ❑Check if revision to previous application 4 \ <br /> [Privacy Law,s. 15.04(1)(m)). State Plan I.D.Number I^TN <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATI N U <br /> Propert Owner Name Property Location <br /> 1/4 1/4,S (� T 3$ ,N, R S E(or)/ <br /> Property Owner's Mailing Address Lot Number r <br /> la*7660 _514i 0112 V43 'L.. .L- <br /> City,State Zip CodeP one Number Subdivision Name or CSM Number <br /> (n_ ) Ro (4 V. 3 <br /> TY ILDING: (check one) E] State Owned ❑ ill - Nearest Road <br /> ❑ age oM <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms Z ToTo wn of <br /> III. BUILDING USE: (if buildingtypeispublic,check alithatapply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo 14 2=6, O3 <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 [_1Church/School 8 E] 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. I eplacement 3. ❑ Replacement of 4. ❑ Reconnection of S. ❑ Repair of an <br /> System S1�stem _ Tank Only _ __ _ __ Existin�iystem ____ _ 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 E]Specify Type 41 ❑Holding Tank <br /> 1 Seepage Trench 22 F1In-Ground Pressure 42❑Pit Privy <br /> 13 E]Seepage Pit 43 E]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.) Propose(sq.ft.) (Gals/dy/sq.ft.) (Min./inch) Elevation <br /> S 40­� 1 q ,I Feet qcf,s 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 structed glass APP <br /> Tanks Tanks <br /> Septic Tank or Holding Tank ' 3 $b I GP El <br /> Lift Pump Tank/Siphon Chamber El El ❑ 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 Signature:(No mps) MP/MPRSW No.: Business Phone Number: <br /> 1� Q s z25ss Its- 5�6 . <br /> PI mber's Address(Street,City,State,Zip Code): <br /> Z-7160 Hwj 3S 1,✓�BsPr� 1�) 8a3 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanl yP rmitFee (IndudesGroundwater ate IssuedIssuing Aqe n gnatur (NoS <br /> ❑ pP <br /> surge eel <br /> proved 171 Owner Given li al ©() C <br /> Adverse Determmination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> DISTRIBUTION: original to County,One copy To: Safety&Buildings Division,Owner,Plumber <br /> SBD-8398(R.4/99) <br />