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Safety and Buildings Division <br /> NVIsconsin <br /> 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 5371)7-7302 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County � , / a <br /> than 8112 x 11 inches in size. ,;/CJ}tu T (� �` <br /> • See reverse side for instructions for completing this application State Sanitary Permit <br /> P-errmitt Neu—mbber <br /> Personal information you provide may be used for secondary purposes ❑Check if revision toprey Dud application cp 1� <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number R <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION I <br /> Property Owner Name Property Location <br /> CJ Gc/ � ©.J A),/4 �f 1/4,S T�7F,N, R Jg <br /> E(orj <br /> Property Owner's Mailing Address Lot Number Block Number <br /> >Q Cri ,,State I Zip Code Phone Number Subdivision Name or CSM Number <br /> II. TYPE OF B IL NG: (check one) ❑ State Owned El '.ty Near st Road / <br /> El age 1��� /d C! it/G <br /> Public 1 or 2 FamilyDwellingTo-No.of bedrooms Town of ls� <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. rvY New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> __ __System ___ __ System _ Tank Only______________ ExistingSystem _______ ExlstfngSystem <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 VWound 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./inch) / Elevation <br /> WO 0 p v S5_ ,� r — / d3, Feet !49�-'Feet <br /> Ca acct <br /> VII. TANK in gallons Total #of Manufacturer's Name Prefab. Site Con- Steel Fiber- plastic Aper. <br /> INFORMATION New Existin Gallons Tanks Concrete structed glass App- <br /> INFORMATION <br /> nks Tanks <br /> Septic Tank or Holding Tank a0() 4,2in ) [I ❑ 11 E] E] <br /> Lift Pump Tank/Siphon Chamber ;7.-d 7J�C� <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 Namq:(Print) Plumber's Signature:(N tamps) MP/MPRSW No.: Business Phone Number: <br /> Plumber's Address(Street,City,State,Zip Code): <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> E]Disapproved <br /> Sanitary Per (Includes(Includes Groundwater 7atssue lssuingAgentSi na (N s) <br /> 422 Surcharge Fee) <br /> ' epgroved ❑Owner Given Initial <br /> MVV 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 />