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Safety and Buildings Division <br /> SA <br /> //��/��•p• ••f• NITARY PERMIT APPLICATION 201 E.Washington Ave. <br /> NARsim sin In accord with ILHR 83.05,Wis.Adm-Code P.O.Box l 53707-7969 <br /> Department of Commerce Madison,WWI <br /> • Attach complete plans(to the county copy only)for the system,on paper not less count /_C) <br /> than 8 1/2 x 11 inches in size. a e- ((� <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 ❑Chec If revision to p evious application <br /> (Privacy Law,s. 15.04(1)(m)]. State Plan I.D. umhar <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION I I 39 <br /> Prope yO ferName // Property Location {�- <br /> /4�(iSL 4" 5�.� Cj/4�r(�J1/4,S T ,N, R 7 E(orr`2J <br /> Property Owner's Mailing Address t Lot Number Block Number <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> Ii. TYPE OF BUILDING: (check one) ❑ State Owned ity (� Nearest oad / <br /> Public 1 or 2 FamilyDwelling- No.of bedrooms � M Towan OF �Il/9� <br /> III. BUILDINGUSE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> �e � <br /> 1 ❑ Apartment/Condo � YI'7 03 <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_ XLReplacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> System System Tank Only ............ Existing System Existing System <br /> ------------------------------------------------ <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 ❑Mound 30❑Specify Type 41,gHolding 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 13. Absorp.Area 4. Loading Rate 5. Perc. Rate 1 6. System Elev. 7. Final Grade <br /> Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> 0 d —�Feet Feet <br /> VII. TANK Capacity Prefab site <br /> INFORMATION in gallons Total <br /> lltons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic Appr <br /> New Existingstrutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank �o D o7De l�f ❑ ❑ ❑ El El <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ ❑ <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 tamps) MP/MPRSW No.: Business Phone Number: <br /> Plumber's Ar dress(Street,City,State,Zip Code): <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee QncludergeFeeGroundwater ratessue Issuing Agent Signature o mps) <br /> roved 01 <br /> o7� ' 3pp ❑Owner Given Initial �l i <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> BBD639B(R.11196) DISTRIBUTION: Original to County.One copy To: Safety&Buildings Division,Owner,Plumber <br /> I — <br />