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6�2 C:t?��yya <br /> Ase6nsin <br /> Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> Department of Commerce In accord with Comm 83.05,Wis.Adm.Code P Box 7162 <br /> Madison,WI 53707-7162 <br /> • Attach complete plans(to the county Copy only)for the system,on paper not less County <br /> than 81/2 x 11 inches in size. aqliql <br /> • See reverse side for instructions for completing this application State Sanitary Permit Num`bbee+r- <br /> Personal information you provide may be used for secondary purposes 2 a�V <br /> ❑ <br /> (Privacy Law,s. 15.04(1)(m)]. Check if revision to previous application <br /> State Plan Review Transaction Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION <br /> Prop e Owner ame Property Location <br /> d: X1/44/e1/4,S J'S T 3JJrN, R /gE(or <br /> Property Owner's Mailing Ad rens Lot Number Block Number <br /> Uf /�rte' csya'I r i4'� <br /> City, ite ZipC e Phone NuSubdivision Name or CSM Number <br /> r G ArOp on � <br /> II. TYPE OF B IL ING: (check one) ❑ State Owned z ❑ Cit Nearest Road <br /> El Public 1 or 2 FamilyDwelling-No.of bedrooms ❑ Village L4� <br /> III. BUILDING USE: (If building type is public,check all thatapply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo —/ —So0 <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 [K New stem 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. [3 Repair of an <br /> y _____ _System Tank Only _ _ ExlstingSystem ___ Exlsti gSystem <br /> B) [I 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 E]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 /> 300 //Required(sq.ft.) Proposed(sq.ft.) (GaWday,/sq.ft.) (Min./inch) �� Elevation <br /> < 9/, 7e Feet 9�1,2 Feet <br /> VII. TANK Capacity <br /> g los Total #of site <br /> INFORMATION Gallons Tanks Manufacturer's Name Prefab. Con- Fiber- plastic Exper- <br /> New ExistingConcrete strutted Steel glass App. <br /> Tank Tank <br /> Septic Tank or Holding Tank rr� Lt/,cSe r 1� � 0 El <br /> Lift Pump Tank/Siphon Chamber I❑6i El El ❑ ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> 1,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> 11 <br /> PI ber's Name:(Pr' ) Plu 's Signa re: to ps) MP/MPRSW No.: Business Phone Number: <br /> o Br ,- <br /> Plumber'sAddress(Street,Cit State,Zip Cyde): / C J <br /> IX. OLINT Y/DEPARTMENT USE ONLY 9944 <br /> ❑Disapproved SanitEPermitee (Includes Groundwater ate ssue IssuinA ntsignatur�mps) <br /> Approved ❑Owner Given Initial Surcharge Fee)Adverse Determination Q0 <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.12/99) DISTRIBUTION: Original to County,one copy To: Safety&Buildings Division,Owner,Plumber <br />