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Gl� Fwjb <br /> Safety and Buildings Division <br /> Als6onsin SANITARY PERMIT APPLICATION 2 1 W.BoWashington <br /> ashingtonAvenue <br /> 302 <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 County 1 <br /> than 81/2 x 11 inches in size. �N � a <br /> • See reverse side for instructions for completing this application State Sanitary Permit Nurfter 1 <br /> Personal information you provide may be used for secondary purposes ❑Check if revision v ous hl o, <br /> [Privacy Law,s. 15.04(1)(m)]. <br /> State Plan I.D.Number <br /> 1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Propert Owner Name Property Location <br /> D G U 1/4 1/4,55� T ,N, R/.:57E(or <br /> Property Owner's Mailing Address Let Nxw6er Block Number <br /> 414 <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> 35/ 67-2 <br /> II. TYPE OF BUILDIN(i: (check one) ❑ State Owned Cl cityill �� � NearestRoad � /� <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms E Town of r NGS/6P <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo 4 4R;?05— <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_ k1leplacement 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 Distributio Pressurized Distribution Experimental Other <br /> 11 Seepage Bed C �l7 21 ❑Mound ' 30❑Specify Type 41 ❑Holding Tank <br /> 12❑Seepage Trench 22❑In-Ground Pressure / 42❑Pit Privy <br /> 13❑Seepage Pit b -k-�ZAL 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(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) p Elevatio <br /> j O O ip-a < a 9 /Z/`/ Feet Feet <br /> TANK Capacct <br /> VII. INFORMATION in allons Total #of Manufacturer's Name Prefab. Site Con- Steel Fiber- Plastic Ex <br /> Aper. <br /> New Existing Gallons Tanks concrete strutted glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank 73-'0 217 ❑ ❑ 1 ❑ 1 ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber 6160 5-DO ❑ ❑ I ❑ 1 ❑ ❑ <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 /> Plumber's Address(Street,City,State,Zip ode): <br /> 4 e X Srl/`tep N G.> �5— tw7 !-;L <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved anitary Permit Fee (include,Groundwater 7 <br /> Date ssue Issuing A err ig a)ure(No t ps) <br /> 'Approved E]Owner Given Initial �76, � <br /> et <br /> Surcharge <br /> ee) �7 <br /> Adverse Dermination <br /> LS , <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> �YII ��cl <br /> SBD-6398(R.4199) DISTRIBUTION: Original to County.One copy To: Safety&Buildings Division,Owner,Plumber <br />