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Safet3r'art9 guildinision <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> V!"insin P O Box 7302 <br /> uCommerce 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 33 �� <br /> than 8 1/2x 11 inches in size. <br /> • See reverse side for instructions for completing this application Sta a Sanitary Permit Number <br /> Personal information you provide may be used for secondary purposes ❑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 -O g <br /> Property_Qwner Name PropLocation � <br /> va ert W 1/4,5 3 T 21 <br /> :T ,N, R (b E(or <br /> Property Maili Address Lot Number Block Number <br /> Ci y S to Zi Code Phone Number Subdivision Name or CS N tuber / <br /> 6,)1 ( Y gX - Q. 330 <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ It y Nearest Road <br /> r] Villa <br /> Public 1 or 2 FamilyDwellingage <br /> -No.of bedrooms 3 own OF <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo 01% 3303 03 ((0 <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. ❑ 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 21'61 Mound 30 C]Specify Type 41 E]Holding Tank <br /> 12 E]Seepage Trench 2 ❑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 S.Perc. Rate 6. System Elev. 7. Final Grade <br /> Requirelq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> Asp 1I0.7-- Feet Feet <br /> VII. TANK Capacity Site Fiber- Plastic Exper. <br /> in gallons Total #of Manufacturer's Name prefab. Con- Steel astic <br /> INFORMATION Gallons Tanks Concrete glass App. <br /> New Existin strutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank ❑ ❑ Q ❑ <br /> Lift Pump Tank/Siphon Chamber III W71V ❑ ❑ <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) Plum rsSignature� No amps) MP/MPRSWNo.: Busin ss Phone Number: <br /> 1'Z.SgSI s $66— S <br /> MW I Plu ber's Address(S reet,City,State,Zip Code): <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved itax Per Fee (includes Groundwater ate ssue Issuing A e ignatu (No s} <br /> ��roved charge Fee) <br /> 'N ❑Owner Given Initial C <br /> Adverse Determination CC//�� <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.4/99) DISTRIBUTION: Original to county,one copy To: Safety 6 Buildings Division,Owner,Plumber <br />