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Safety and Building ivision <br /> ``fi�tt SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> N�isconsin P O Box 7302 <br /> In accord with(LHR 83.05,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���� <br /> than 8 112 x 11 inches in size. <br /> • See reverse side for instructions for completing this application State Sanitary Permit NNQumbeer IPersonal information you provide may be used for secondary purposes [ICheck it revisiorC0 prh us applin <br /> (Privacy Law,s. 15.04(1)(m)1- State Plan I.D.Number S 3 <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Prope YO�j'er Name Property Location <br /> oIntN 161 &)a he r` �fi/4 AM1/4,5 �� T 37 ,N, R /fir(o W <br /> Property Owner's Mailing dress L Number Block Number <br /> a loNoC �� > i <br /> ty,51ate / Zip Code Phone Nu r Subdivision Name or CSM Number <br /> {S� N �oyy (61r' ) 3 <br /> e r <br /> Ill. TYPE OF BUILDING: (check one) ❑ State Owned ❑ ty Nearest Road <br /> ❑ Village <br /> Public SL 1 or 2 Family Dwelling-No.of bedrooms ��rg To of C. ` � <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> b_�3q ! 5 � 'dam flZ7� <br /> 1 ❑ Apartment/Condo <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. � Replacement 3. E] Replacement of 4. E] Reconnection of 5. E] Repair of an <br /> System System ------------- Tank Only_-____________ Existing System Existing System <br /> _____ ________ <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 16. System Elev. 7. Final Grade <br /> Required(sq. ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) (� Elevation <br /> 7 7 66 Feet 4f ° Feet <br /> VII. TANK Capacity Site <br /> r. <br /> INFORMATION in gallons Total s Tanks Manufacturer's Name Concrete Con- Steel glass Plastic Appp, <br /> New Existin strutted <br /> Tanksl Tanks <br /> Septic Tank or Holding Tank 'j paQ f �? ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber El El ❑ <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) PI be 's Sign tures to Stam s) /MPRSW No.: Business Phone Number: <br /> w r H <br /> 4z3 6 7 <br /> Plumber' A ciress(Street,City, tate,Zip Code): <br /> Li C <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit (includes Groundwater ate slueA <br /> Issuing A e jdgnatv?Nj(7Z�P� <br /> p ❑ �� v/VS urcharge Fee)roved Owner GivenInitial � <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.11/97) DISTRIBUTION: Original to County,One copy To: Safety&Buildings Division,Owner,Plumber <br />