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Safety and Buildi gs Division <br /> Visconsin SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> 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 <br /> than 8112 x 11 inches in size. — a�(ol <br /> • See reverse side for instructions for completing this application State sanitary Permit Num¢er <br /> Personal information you provide may be used for secondary purposes ❑Check if«ividforfero evious appli�tion <br /> qq <br /> [Privacy Law,s. 15.04(1)(m))- <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF ORMATI N /V <br /> Propelty Owner Name / Property Location <br /> TR bj/4 ,,j tg iA,S T -'/ak ,N, R /'SrE(or) <br /> Propertywner 's Mailing Address Lot Number Block Number <br /> I,Sta <br /> CityZip Code Phone Number Subdivision Nameor CSM Numb <br /> P r <br /> W 51 ( )sly s — 9 <br /> 11. T F BUILDING: (check one) ❑ State Ownedit Nearest Road <br /> Public or 2 Famil Dwellin -No.of bedrooms A village TWC k Q <br /> Town OF Spit..) c O, /� cA <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo 124-.2 GD Qc) <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. New 2- ❑ Replacement 3_ ❑ Replacement of 4_ ❑ Reconnection of 5. ❑ Repair of an <br /> ---- System ----- --System ------------- Tank Only----------- Existing System 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 /> 1 1eepage Bed 21 Mound 30 Specify Type 41 Holding Tank <br /> 12ESeepage E] C] E]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/day/sq.ft.) (Min./inch) Elevation <br /> �t�6 ' Feet 7 Feet <br /> VII. TANK Capacity <br /> INFORMATION in gallons Total #of Manufacturer's Name Prefab Con- Fiber- plastic Exper. <br /> New ExistingGallons Tanks concrete Steel glass App. <br /> Tanks Tanks <br /> structed <br /> Septic Tank or Holding Tank C) n ❑ <br /> Lift Pump Tank/Siphon Chamber � E] � El 13 E] <br /> VIII. RESPONSIBILITY STATEMENT <br /> 1,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Na/me:(Print Plumber's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> Plumber's Address(Street,City,State,Zip Code): <br /> /- z /^ GU <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved S tar Permit Fee (includes Groundwater ate ue Issuing A n ignat ( s) <br /> roved Opp\Surcharge Fee) <br /> pp E]Owner Given Initial /—At/1 <br /> Adverse Determination <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 />