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Safety and Buildings Division <br /> ®�: - SANITARY PERMIT APPLICATION 201 E.Washington Ave. <br /> Wisconsin 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 Count <br /> than 8 1/2 x 11 inches in size. C_ Q,2-_�(15 <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> The information you provide may be used by other government agency programs <br /> ❑Check it rewslon to revi application <br /> [Privacy Law,s. 15.04(1)(m)). State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION I (� <br /> Property Own Name / / 1 Property Location <br /> a/e�J 1/4 1/4,5 TN, R /`/E(or W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 6 e <br /> City,State Zip Code Phone Number Subdruision Name or CSM Number <br /> ,f7ofr4 'In/0 —s 1(,5_07442- 71Y,2 V <br /> II. TYPE F BUILDING: (check one) F] State Owned ityI Nearest Road <br /> Public 1 or 2 FamilyDwelling-No_of bedrooms El rowan OF �o i <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) o <br /> 1 ❑ Apartment/Condo Ic-,D,� <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_ E] Replacement 3. ❑ Replacement of 4. E] Reconnection of 5_ E] Repair of an <br /> System <br /> ___ ________System ____________ Tank______ly _____________ Existing System _____ExlstingSystem <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 [aSeepage 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 S. Perc. Rate 6. System Elev. 7. Final Grade <br /> Required (sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> yeti% 2 1 n",a Feet �� G Feet <br /> Capaclt <br /> VII INFORMATION in allo s Total #of Manufacturer's Name Prefab co Steel Fiber- Plastic Exper <br /> New Existin Gallons Tanks Concrete strutted glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber S dC 57"6 rJ ® ❑ ❑ ❑ I ❑ ❑ <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:(No S amps) MP/MPRSW No.: Business Phone Number: <br /> Plumber's A(dress(Street,City,State,Zip Code): <br /> ee,k 5-/',n 2AJ P ?-Z,- <br /> IX. <br /> -2IX. COUNTY/ DEPARTMENT USE ONLY <br /> X <br /> ❑Disapproved Sanitary Permit Fee (includes Groundwater ate ssue Issd g gent Sin ure(No Stamps) <br /> Approved ❑Owner Given Initial d/ <br /> Surcharge I") <br /> Adverse Determination P /G <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.11196) DISTRIBUTION: Original to County.One copy To:Safety 8 Buildings Division,Owner,plumber <br />