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Safety and Buildings Division <br /> ,• -�VSANITARY PERMIT APPLICATION 201 W.Washington Avenue iscons�n P O Box 7302 <br /> DepartiTient of Commerce In accord with Comm 83.05,Ms.Adm.Code Madison,WI 53707-7302 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County �y <br /> than 8112 x 11 inches in size. /`i1J Sia QJ <br /> • See reverse side for instructions for completing this application State Sanitary PermittNN'umbe <br /> Personal information you provide may be used for secunda purposes � ` s <br /> y p y secondary p p ❑Check it revision o previous application 1 <br /> [Privacy Law,s. 15.04(1)(m)1. State Plan I.D.Num s%j1 <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATIONO2 �S <br /> Proff qy O ner Namt Property Location <br /> rr/ S 1l� 5W114,,.),`1114,5,25? T N, Rl6E(or� <br /> Prope y Ow er's Mailing Address Lot Number -F S N Lt <br /> E_ / Block Number <br /> /4CJ te, 6-07�00 <br /> t)r,State Zip Code Phone Number S b� ; ame or CSM Number <br /> r c-e GA-K� ��` ( ) S3 a S 3 <br /> 11. E OF BUILDING: (check one) ❑ State Owned ❑ city Near st Road <br /> ❑ village mid-tiClW O74 ::T-5"Public 1 or 2 FamilyDwelling-No.of bedrooms own of <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 E] Apartment/Condo D` 8-33a -OL/-ZD <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. MNew 2. [:] Replacement 3_ E] Replacement of 4. E] 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 21❑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 LPe . Rate 6. System Elev. 7. Final Grade <br /> Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) nch) Cy Elevation <br /> SD 7r ,3 5— /, / Feet O -- Feet <br /> Capacity <br /> VII. INFORMATION in gallos Total #of Manufacturer's Name Prefab Con Steel Fiber- plastic Exper Existin Gallons Tanks Concrete strutted glass App- <br /> New <br /> nks Tanks <br /> Septic Tank or Holding Tank /6v() I <br /> //MOO ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber O6v i6�O ❑ ❑ ❑ ❑ ❑ <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/MPRSWNo.: Business Phone Number: <br /> Plumber's Address(Street,City,State,Zip Code): y— _V <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sa itary Permit Fee (includes Groundwater Date Issued IssuinyAntn t o Stamps) <br /> AAWoved 171Surcharge Fee) / <br /> Owner Given Initial '7 r u Oz7 <br /> Adverse Determination at <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.4/99) DISTRIBUTION: Original to County,One copy To: Safety 8 Buildings Division,Owner,Plumber <br />