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ctylAlb <br /> Safety end Buildin s Division <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> isconsin P O Box 7 I <br /> • In accord with Comm 63.05,Wis.Adm.Code Madison,WI 53707-7302 <br /> Department of Commerce <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County nFR3'+jW0 <br /> than 81/2 x 11 inches in size.• See reverse side for instructions for completing this application State Sanitary Permit�Personal information you provide may be used for secondary purposes ❑Gheck if revision to p[Privacy Law,s. 15.04(1)(m)). State Plan I.D.NumbI. APPLI ATI N INF RMATION - PLEASE PRINT ALL INF RMATIONoperty Owner Name _ PropertLocation2 X1/4 S61/4,S T 3 Property Owner's Mailing Address Lot Number Block N <br /> Cit ,StateS r Zip Code Phone Number Subdivision Name or CSM Number <br /> YP B I IL (check one) ❑ State Owned '.t Nearest Road <br /> ❑ Village II o <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms Town OF 1-144e wood � Pct. <br /> III. BUILDINGUSE: (If building type is public,check all that apply) Parcel TaxNumber(s) 7 <br /> 1 ❑ Apartment/Condo D`T� ^�S�s_ D 3100 <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. F] Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> __- 5 stem System --------- ---Tank Only ..............Existing System--------- Existing Srste- <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 N 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 5.Perc. Rate 6. System Elev. 7. Final Grade <br /> Required Lq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> y�� 3-7s .-7 �1/ ���/�- Feet 0Z, 42-Feet <br /> VII. TANK Capacity Total #of Site Plastic <br /> in gallons Manufacturer's Name Prefab. Con- Steel Fiber- Aper. <br /> INFORMATION New Existin Gallons Tanks concrete strutted glass App. <br /> Tanks Tank <br /> Septic TankorHolding Tank /DOC lti° 2Y ® F-c <br /> 1:1 1 El❑ El ❑ <br /> ift Pump Ta k/Siphon Chamber rwo <br /> VIII. RESPONSIBILITY STATEMENT " <br /> I,the undersigned,assume responsibi ity for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name:(Print) Plu ber'sSignat e: Stamps) MP/MPFtSWNo.: Business Phone Number: <br /> LS o-ew r Lz�2-2_y 7�� <br /> PIusddrgSs Street,C(jy,StL/�e�Zi ode): / p , 1t r' e y <br /> IX. COUNTY/DEPARTMENT USE ONLY er WP�I� sue v <br /> Disapproved Sanl ry Permit Fee (includes Groundwater ate ssue Issuing Agen;Signatur o S m <br /> ❑ pp surcharge Fee) <br /> —3 <br /> Approved ❑Owner Given Initial �D0 tF,/�/`�J <br /> Adverse Determination ' <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> DISTRIBUTION: Original to county,One copy To: Safety&Buildings Division,Owner,Plumber <br /> SBD-6398(R.4199) -- <br />