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tl <br /> SANITARY PERMIT APPLICATION Safety and BuildingsUvNon <br /> Vtsconsin 201 E.Washington Ave. <br /> In accord with ILHR 83.05,Wis.Adm.Code P.O.Box 7969 <br /> Department of Commerce Madison,WI 53707-7969 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less coDDt <br /> than 81/2 x 11 inches in size. 5Q3C <br /> • See reverse side for instructions for completing this application StarKSa <br /> 'n iitta ryy P�erm lit <br /> Nu mm be <br /> The information you provide may be used by other government agency programs E]Chec1;rev�SioTFfo previc sWIication <br /> [Privacy Law,s. 15.04(1)(m)]. <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION <br /> Property Owner Name Property Location f,, <br /> Iva va,S s T ,N, R E(or Y <br /> Property Owner's Mailing Address Lot Number Block Number (U <br /> City,Sta e� ` Zip Code Phone Number SubdivisionsName oorr CSM Number <br /> ( ) <br /> II. TYPE BUILDING: (check one) ❑ Statd Owned ❑ City Nearest Road <br /> Public jo 1 or 2 Family Dwelling-No.of bedrooms � ❑ Iowan OF r� .GDNNORS Lie.RD, <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo ©Zw 4335 0(o 5t)(5 <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. 5Vdew 2. ❑ Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5. ❑ Repair of an <br /> ____,'_-System System Tank Only Existing System Existing System <br /> ------------------------------------------------------------------------------------------- <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�ffNlound 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 /> /,,�� Requ�irend(sq.ft.) Prop sed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) / Elevation <br /> (000 ,�jDD 4 .Z — U e 4 FeetqCj.Z_Feet <br /> TANK Ca act <br /> VII. INFORMATION in gallons Total #of Manufacturer's Name Prefab. Site Con- steel Fiber- Exper <br /> Gallons Tanks Concrete glass Plastic App <br /> New Existin structed <br /> Tanks Tanks <br /> Septic Tank or Holding Tank ❑ ❑ I ❑ ❑ ❑ <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:a0 *--, N St s) MP/MPRSW No-: Business Phone Number: <br /> 1 CJI SLS l 1 y <br /> Plu ber's Ar dress(Street,City, te,Zip Code): <br /> b 1wS la <br /> IX. C UNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Fee (includes Groundwater ate ;su d Issuing Age t Si naturNo a s) <br /> roved []Owner Given Initial Qv 3;uhargeFee) <br /> pp <br /> Adverse Determination W `� <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.11/96) DISTRIBUTION: Original to County.One copy To: Safety&Buildings Division,Owner,Plumber <br />