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Safety and Buildings Division <br /> Visconsin SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> Department of Commerce In accord with Comm 83.05,Wis.Adm.Code M diisson,WI253707-7302 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County Q I <br /> than 81/2 x 11 inches in size. <br /> • See reverse side for instructions for completing this application s ate Sanitary Permit Number .� <br /> Personal information you provide may be used for secondary <br /> Y P Y purposes <br /> [Privacy Law,s. 15.04(1)(m)]. ❑Check if revision to previous application <br /> State Plan I.D.'119(o <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION <br /> Prope Owner Name Property Location <br /> t/a t/a,S T N, R 4 E(o W <br /> Property Owner's Mailing Address Lot Number g <br /> 7&940 LL 3 <br /> City,State Zip Code Phone Number Subdiv ion Name r CSM Number <br /> 11. TYPE OF BUILDING: (check one) ❑ State Owned 0 f rty Nearest Road <br /> ❑ VII age <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms Town OF a- <br /> III. BUILDING USE: (if building type is public,check allthatapply) Parcel Tax Number(s) <br /> 1 E] Apartment/Condo Vs 412!i; 0- '700 <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_ E] Replacementof 4. E] Reconnection of 5. E3 Repair of an <br /> ------System ____--__System ............. TankOnly---------------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 ❑Seepage Bed 2.1k 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 /> Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inc Qevation <br /> 5vo 250 woo .$3 9-, Feet _52-Feet <br /> acct <br /> VII. TANK in Caallons Total #ofPrefab. Site Fiber- Exper <br /> INFORMATION New ExistingGallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> El <br /> Septic Tank or Holding Tank !�Q ❑ El ❑ El <br /> Lift Pump Tank/Siphon Chamber ❑ 11 ❑ <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:( S ps) MP/MPRSW No.: Business Phone Number: <br /> c A ?Z S !S 6-7 <br /> PI tuber's Address(Street,Cit ,State,Zip Code): Fir <br /> 2-77 J6 K Li/I. <4423 <br /> IX. COUNTY/DEPART ENT USE ONLY <br /> ❑Disapproved San aryPermitFee (Includes Groundwater ate IssuedIssuing Age Signa r ps) <br /> Cpproved E]Owner Given Initial �7 Surcharge Fee) <br /> 9NAdverse Determination oC (� <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6396(R.4/99) DISTRIBUTION: Original to County,One copy To: Safety&Buildings Division,Owner,Plumber <br />