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Safety and Buildings'Dv <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> Visc6nisin 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 Coun � <br /> than 8112 x 11 inches in size. G <br /> 70 <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number 0 <br /> Personal information you provide may be used for secondary purposes ❑cnecrhvisZn to�p vio application <br /> [Privacy Law,s. 15.04(1)(m)]. <br /> State Plan LD.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATI N <br /> Property Owner Name Property Location (� <br /> r wtla C 1/4,Sr T�9 ,N, R ` E(OrU <br /> Property Owner's Mailing Addr ss Lot Number Block Number <br /> S' <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> 11. PE OF BUILDING: (check one) ❑ State Owned0 C,it < Nearest Road <br /> LiVillage <br /> Public 1 or 2 Famil Dwellin -No.of bedrooms Town OF�/i(1Co GO. <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo 0 IZ — -7 C3' Z 6 ya <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, KNew 2. E] Replacement 3. E] Replacementof 4. E] Reconnection of 5. ❑ Repair of an <br /> -------ystem --------System----- <br /> ------- Tank Only-------------- Existing System Existin System <br /> B) E] 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 XMound 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 /> "300Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) pq / Elevation <br /> 4 0�S�— /� ,Z / /• i Feet /p a Feet <br /> cit <br /> VII. TANK inCagallons Total #Of Prefab. Site Fiber- Exper <br /> INFORMATION New Existin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank a El El 1:1 1] <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 Name:(Print) Plumber's Signature:( Stamps) MP/MPRSW No.: Business Phone Number: <br /> �� �r �a � <br /> Plumber's Address(Street,City,State,Zip Code): <br /> Dx-1/ GitJ AJ <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑DisapprovedSanitary Permit Fee OndudesGroundwater ate IssuedIssuing A ent Signature(No Stamps) <br /> Approved <br /> C]Owner Given Initial �} Surcharge Fee) <br /> Adverse Determination - &CFO, <br /> X. ONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.4/99) DISTRIBUTION: Original to County,One copy To: Safety&Buildings Division.Owner,Plumber <br />