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l� ctr / Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> 160donsin In accord with ILHR 83.05,Wis.Adm.Code P D 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. <br /> • See reverse side for instructions for completing this application S to Sanitary Permit Number h <br /> G3 u <br /> Personal information you provide may be used for secondary purposes ❑Check if to previous application <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATI N <br /> Prop Owner Name Property Location <br /> T4 <br /> 1/4 1/4,S T N,-R E(or nW <br /> Prop rty Owner's Mailing Ad ress Lot Number Block Number <br /> D i <br /> Cit ,Stat Zip Cod I P one Number Subdivis n Name or C Number <br /> c . M ( > is tss VILLA46 ovRms <br /> II. TYPE 01- BUILDIN1133: (check one) ❑ State Owned o City Nearest Road <br /> Public 1 or 2 Famil Dwellin -No.of bedrooms 2 Town OF ) QVA GRcc.E <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo 032 <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 /> -_-__System ____- _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 /> 11Seepage Bed 21 ❑Mound 30 E]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 /> Req 'red(sq.ft.) Proposed(sq.ft.) (Gals/da /sq.ft.) (Min./inch) Elev tion <br /> 2 , ��_ 95-6 <br /> `5-6 Feet .Q Feet <br /> TANK Ca cit <br /> VII. INFORMATION in gal to 5 Total #of Manufacturer's Name Prefab. Con steel Fiber- plastic Exper <br /> New Existin Gallons Tanks Concrete strutted glass App- <br /> New <br /> TanksTank <br /> Septic Tank or Holding TankC ❑ ❑ El ❑ 11Lift 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 /> Pu er's Name:(Print) Plumber's Signature:(N St s) Business Phone Number: <br /> +4A)Zp nl f rIMP/MPRSWNo.: <br /> Sd5-1 q15 14y- <br /> Plumber's Address(Street,City,Sta e,Zip Code): <br /> :7_1n w35V195SAQ-Z ll. U, <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee ll"ciudesGroundwater Date Issued Issuing g t Signature(No to s) <br /> roved Surcharge Fee) <br /> 110 ❑Owner Given Initial e -9 <br /> Adverse Determination c��/ , <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.11/97) DISTRIBUTION: Original to County,One copy To: Safety 8 Buildings Division.Owner,plumber <br />