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` Safety and Buildings Division <br /> �� SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> Tisconsin 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 County <br /> than 81/2 x 11 inches in size. el ^^j e.. <br /> • See reverse side for instructions for completing this application State Sanitary Permit Numbeerrr <br /> Personal information you provide may be used for secondary purposes � <br /> ❑Check if revisi;on to previous ap Ion <br /> IPrivacy Law,s. 15.04(1)(m)]. ' State Plan I.D.Number X/ <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATI N IV <br /> Property Owner Name Property Location <br /> J"p ,u L/,¢�q�m.r 0/--> 1/4 1/4,S -2 T %> N,R I —E(or W� <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 8� 7 dao y Aum <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> �, 5�7� ( >y� =%l�� if k / <br /> IL TYPE OF BUILDING: (check one) ❑ State Owned CitNearest Road <br /> ❑ Village /1 <br /> Public or 2 Family Dwelling-No.of bedrooms 1;2 Town OF it c,k S o 17�7 6- J <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo 7 <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 /> ---__Syrstem ____ __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 /> 11 R1 Seepage Bed 21 ❑Mound 30❑Specify Type 41 ❑Holding Tank <br /> 12N 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 /> `�j�-� Required(sq.ft.) Pro osed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Q� Elevation _ <br /> -c/ c ,3 �� �� /--5 Feet / 7- Feet <br /> TANK Ca cit Site <br /> VII. FORMATION in gallons Total #of Manufacturer's Name Prefab. Con- steel Fiber- Exper. <br /> Gallons Tanks Concrete glass Plastic App <br /> New Existin strutted <br /> Tank Tanks ry� <br /> Septic Tank or Holding Tank 5-ela <br /> /-I 6j ❑ ❑ I ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ 1 ❑ 1 ❑ ❑ <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:(PrinPlumber's Signature:( tamps MP/MPRSW No.: Business Phone Number: <br /> Plumber's Address(Street,City,Stale,Zip Code): y <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved S itary Permit Fee (includes Groundwater ate.IssuedIssuing A nt Si atur ( Stamps) <br /> *"pro*"proved ❑Owner Given Initial (55hharge Fee) f <br /> ved <br /> Adverse Determination 1 S' l _ -a` <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.11197) DISTRIBUTION: Original to County.One copy To: Safety&Buildings Division,Owner.Plumber <br />