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Safety and Buildings Division <br /> Visconsin <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> In accord with ILHR 83.05,Wis.Adm Code P O Box 7302 <br /> Department of Commerce Madison,WI 53707-7302 <br /> • ' Attach complete plans(to the county copy only)for the system,on paper not less County <br /> than 8 1/2 x 11 inches in size. & PIPb () - <br /> • See reverse side for instructions for completing this application State Sanitary Permit Nu��mjj �r <br /> Personal information you provide may be used for secondary purposes ❑Checkvion to previus application` X/ <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION 1 00 <br /> Property Owner Name Property Location <br /> I U .e/' A Aj !e.0 1/4 1/4,S a T9 N, RjL E(or)C <br /> Property Owner's o Mailin Address Lot Number Block Number <br /> " <br /> City,Stat Zip Code Phone Number Subdirisien Name or CSM Number <br /> Va-7/9 a <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned Lfty Neare Road / <br /> Public 1 or 2 Famil Dwellin No.of bedrooms >� R Vown 0FW1e <br /> III. BUILDING USE: (If building type is public,check all that apply) Par el 1,ax_AprrNumber(s) —/ <br /> 1 ❑ Apartment/Condo3-3;'-T' / ,�: � <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. ❑ Replacement of 4. ❑ Reconnection of 5_ ❑ Repair of an <br /> __SLfstem _ _ _System _ ____ _ Tank Only___ _ ___ 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 BedC c�/ 21 ❑Mound 30❑Specify Type 41 ❑Holding Tank <br /> 12 Seepage Trteacls 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 /> o D D17 1 02 " — 9�Y/S Feet 76/SFeet <br /> VII. TANK Capacltallons Total #of r Prefab- Site Fiber- Exper. <br /> INFORMATION in g Gallons Tanks Manufacturers Name Concrete con- Steel glass Plastic App <br /> New Existin structed <br /> Tanks Tanks <br /> Septic Tank or Holding Tank 4 `��i� <br /> U EIL El I El I El El <br /> Lift Pump Tank/Siphon Chamber E] <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:(N tamps) MP/MPRSW No.: Business Phone Number: <br /> Plum er's Address(Street,City,State,Zip Code): j <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved anitary Permit Fee (includes Groundwater ate slue Issuing Age Sig re s) <br /> roved �.SYf�hargeFee) <br /> pp ❑Owner Given Initial <br /> Adverse Determi atlon <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.11/97) DISTRIBUTION: Original to County.One copy To: Safety&Buildings Division,Owner,Plumber <br />