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64Z06 <br /> Safety and Buildings Division <br /> 302 Z- 1 <br /> Vlic <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> onsin P°Bon,WI <br /> In accord with[LHR 83.05,Wis.Adm.Code Madison,WI 53707-7302. <br /> Department of Commerce <br /> • Attach complete plans(to the county copy only)for the system,on paper not less Co my f� 0 <br /> than 8 1/2 x 11 inches in size. d� /v �. <br /> StateSanitar ermitNumber <br /> • See reverse side for instructions for completing this application Y-363% <br /> �6 3�� Q <br /> Personal information you provide may be used for secondary purposes ❑Check if revis n to previous application <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> 1. APPLICATION INFORMATION - PLEASE PRINT ALL INFO RMATI N <br /> Propertwn r Name Property Location <br /> I F . 1/4 1/4,S T40 ,N, R ej E(or(f2 <br /> Prop rty Ow er's Mailin Addre s Lot Num er Wo&-Member <br /> S 2 17 ST: 1�• 5 2 <br /> City, tate MZ Code SS 2 PhonelNumber <br /> -Q Subdivision Name or CSM Number <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned '0] It Nearest Road <br /> p Village <br /> Public J&1 or 2 Family Dwelling-No.of bedrooms 3bfTown OF I <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo 1 36- ,13 <br /> 2 ❑ Assembly Hall 6 ❑ Medica[ Facility/Nursing Home 10 ❑ Ob or reational 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. ;d New 2. ❑ Replacement 3_ ❑ Replacement of 4_ ❑ Reconnection of 5_ ❑ Repair of an <br /> __System __ _ __ _System Tank Only .............Existing System -------- ExistlnqSystem <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'gseepage Bed 21 ❑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./inch) Elevation <br /> I93 ��-$ — .I Feet S.G Feet <br /> VII. TANK Capacity site <br /> in gallons Tota[ #of Manufacturer's Name Prefab. Con- Steel Fiber- plastic Exper <br /> INFORMATION New Existing Gallons Tanks Concrete strutted glass App <br /> Tanks Tanks 1� <br /> Septic Tank or Holding Tank Q�Q —�� [OCC - KA Q El ❑ <br /> Lift Pump Tank/Siphon Chamber Ej El 11 r] El <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 Name:(Print) Plumber's Signature:(No Stamps) rMP/MPRSW No.: Business Phone Number: <br /> Pkr� 22585'! 5• S", S? <br /> P tuber's Address(Suet,City,,4tJate,Zip Co / r I I 1 <br /> IX. COUNTY/DEPARTMENT USE ONLY W 5 <br /> E]Disapproved Sanitary Permit Fee (Includes Groundwater ate ssue Issuing Agen 5 nature N ) <br /> Approved charge Fee) <br /> pp ❑Owner Given Initial � <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FO DISAPPROVAL: <br /> SBD-6398(R.11/97) DISTRIBUTION: Original to County,one copy To: Safety&Buildings Division,Owner,Plumber <br />