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Visconsin <br /> Safety and BLil ings DivisiNoP <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 Coun <br /> than 8 1/2 x 11 inches in size. n, e, "fiL49 <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> Personal information you provide may be used for seconds purposes <br /> y p y secondary p p Check if revision to previous application <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION 7 b7�3 GO <br /> PropertKOwner Na a Propert Location <br /> �-1/4�r^' 1A,S� y T7,N, R/2E(ore <br /> Propert Owne 's Mailing Addrevs Lot Number Block Number <br /> r R41 <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> II. TYPE F BUILDING: (check one) E] State Owned 0 't� t /`� <br /> Nearest Ro d <br /> ❑ Vii age n ^� <br /> Public 1 or 2 Famil Dwellin -No.of bedrooms Town of (JIT 'e.I LsV © <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo I Wo—a414— 0-c- 9co <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. Z 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 /> 11 %Seepage Bed 21 ❑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 /> �/ ` Requir sq.ft.) Proposed(sq.ft.) (Gals/da /sq.ft.) (Min./inch) Elevation <br /> 7 0 p� , '' i 3 Feet �� Feet <br /> TANK Capacity VII. FORMATION in gallons Total #of Manufacturer's Name Prefab Concrete cso�_ A <br /> Steel Fiber- Plastic per. <br /> New Existing Gallons Tanks strutted glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank 0760ol W400A2? <br /> � � ❑ ElF1 ❑ 1:1Lift 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)Q Plumber's Signature;(No mps) IMPYMPRSWNo.: BusinessPhone <br /> �Number- <br /> Plum er's Address(Street,City,State,Zip Code): <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (Includes Groundwater ate IssuedIssuing Agent ' natur No t ps) <br /> -P-4--proved Surcharge Fee) C� <br /> pp ❑Owner Given Initial / 7,� <br /> Adverse Determination / G [ <br /> X. CONDITIONS OF APPROVAL/REASONS F SAPPROVAL: <br /> SBD-6398(R.4/99) DISTRIBUTION: Original to County.One copy To: Safety&Buildings Division,Owner,Plumber <br />