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Cn <br /> Safety and Buildings Division <br /> 84sconsin SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> In accord with ILHR 83.05,Wis.Adm.Code P O Box 7302 <br /> Department of Commerce Madison,WI 53707-7302 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less Count a I& 5� <br /> than 8 12 x 11 inches in size. <br /> • See reverse side for instructions for completing-this Sta a Sanitary Permit Number <br /> Personal information you provide may be used for seconds p �� 1 <br /> y p y secondary purposes Check it r t r�kion <br /> (Privacy Law,s. 15.04(1)(m)]. State Plan I.D.NumbeA <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFO RMATI N <br /> Prope=Owner Name Propert ocation <br /> keW1A,5 2„4 T7 ,N,R E(or W <br /> Property Owner's Mailing AddressM - Lot Number Block Number <br /> 2 So WW <br /> Cily,State Zi Code Phone-Number Subdivision Name or CSM Number <br /> >EE)IM PWI . $37 ( S 234`1'-1783 IZO ALRES <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned 0 :tyy Nearest Road <br /> ❑ Village <br /> Public CC 1 or 2 Family Dwelling-No.of bedrooms 3 Town OFTjkAD6 UC. <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo <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. Ig New 2. ❑ Replacement 3, ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> System stem <br /> ___ ___Sy _____________ Tank Only_________---__ Existing System _-_---___ExlstlnqSystem <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 M Seepage Bed 21 ❑Mound 30❑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 /> Regyired q.ft.) Proposed sq.ft.) (Gals/day/sq.ft.) (Mein/nch) �6� O Elevation <br /> 45V 1 ��p g Feet 06.O Feet <br /> Capacity VII. TANK in gallons Total #Of Prefab. site Fiber- Exper. <br /> INFORMATION g Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App <br /> New Existin strutted <br /> Tanks Tan g <br /> Septic Tank or Holding Tank AW TZ I ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber I I ❑ I ❑ ❑ I ❑ I ❑ ❑ <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) I Plum er's Signature:(N to MP/MPRSW No.: Business Phone Number: <br /> c AR S " S <br /> Plum is Address treet,City,State, i Code): <br /> IX. COUNTY/DEPARTMENT E ONLY W <br /> ❑Disapproved Sanitary Permit Fe oncludes Groundwater ate slue lssuingAgent Signature( oS amps) <br /> Aroved Surcharge Fee) <br /> pp ❑Owner Given Initial /y a !� <br /> CD <br /> Adverse Determination �D �! <br /> X. CONDITIONS OF APPR AAL/REASONS FO DISAPPROVAL: <br /> a L, <br /> SBD-6398(R.11/97) DISTRIBUTION: Original to Cou y.One c py To: Safety&Buildings Division,Owner,plumber <br />