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*6onsin <br /> Safety and uildings Div sion <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 53707-7302 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less county <br /> than 81/2 x 11 inches in size. e, (1 1 <br /> • See reverse side for instructions for completing this application State SanitaryPermit�mb,�r <br /> Personal information you provide may be used for secondary purposes C]Check i visl(k previous application �) <br /> (Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Numbef <br /> 1. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION <br /> Propert Owner Name// / ,j Property Location <br /> e IU CA �� ('z N:tl4NC t/4,sa3 T t`/6 ,N, R/� E(or0 <br /> Property Owner's Mailin6 Address Lot Number Block Number <br /> r�zO /dam <br /> City,State Zip Code Phone Number Subdivision Name Or CSALNumber <br /> II. TYPE OF BUILDING: (check one) ❑ State Ownedo Vli" ge ar Nearest Road <br /> �jLiOPCS <br /> Public 1 or 2 FamilyDwelling- No.of bedrooms Town of bA� 1 ,6,4.5-S L <br /> III. BUILDIN USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo 0 636 6 O O tv a 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. V New 2. ❑ Replacement 3_ ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> ------Syrstem ___ ___System __________ _ Tank Only---------------Existin9System ----------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 /> 1 1Seepage Bed 21 E]Mound 30❑Specify Type 41 E]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 /> 3 O U y,2 Z 1 C,/ � Feet97� Feet <br /> Ca acct Site <br /> VII. INFORMATION in gallons Total #of Manufacturer's Name Prefab. Con- steel Fiber- plastic Exper <br /> New Existing Gallons Tanks Concrete strutted glass App. <br /> Tanks Tank / <br /> Septic Tank or Holding Tank ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ <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 N me:(Pri t) Plumber's Signature: No Stamps) MP/MPRSWNo.: Business Phone Number: <br /> Plumber's Address(Street,City,State,Zip Code): <br /> O / <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved anitary Permit Fe <br /> B.(Includes Groundwater ate }sue Issuing Ag t gnat (N ps) <br /> ZSurcharge Fee) // <br /> F-1 Owner Given Initial -7 �,�j <br /> 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 />