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%6onsin <br /> Safety and Buildings Divi ion <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> P 0 Box 7302 <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 R <br /> than 8112 x 11 inches in size. U <br /> • See reverse side for instructions for completing this application Sta a Sanittary�P�ermc5 Nu7ber <br /> Personal information you provide may be used for secondary purposes ❑Check itlevislon to previous application <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Nurrbgr [� <br /> I. APPLICATION INFORMATION- PLEASE PRINT ALL INF RMATI N I /(/ /,�A <br /> Propeay.Qwner Nam Property Location <br /> UAW <br /> 1/4 1/4,S T40 ,N, R 14E(or)W <br /> Propert Owner's Mail g Addr s Lot Njmber r <br /> 1 <br /> State Nl7 Zip Coe Pone Number Subdivision Name CS umber <br /> 3 a garAt, 17 <br /> 1111. P IL NG: (check one) ❑ State Ownedty �+ Ne rest Road <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms 3 0,rowan OF �� t.004 Lit <br /> III. BUILDINGUSE: (If building type is public,check all that apply) Parcel Tax Numb s) <br /> 1 ❑ Apartment/Condo ao s giQu—®�^ <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.�R/New 2. E] Replacement 3. E] Replacement of 4_ E] Reconnection of 5. [:] Repair of an <br /> --- System ___ _ System _____ ___ _ Tank Only---------------ExistinQSystem----------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 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 /> Required(�Jlsq.ft.) Pro ose (sq.ft.) (Gal�ay/sq.ft.) (Minim /=) IA Elevation <br /> "t D Feet Feet <br /> Capacity <br /> VII. INFORMATION in gallo s Total #of Manufacturer's Name Prefab. Con Steel Fiber- Plastic Exper. <br /> New Existin Gallons Tanks Concrete strutted glass App. <br /> Tanks I Tanks <br /> Septic Tank or Holding Tank joco QQO ❑ ❑ ❑ I ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ ❑ <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: raps) MP/MPRSW No.: Business Phone Number: <br /> 7.2SSS� 7r� - 41fS <br /> PI ber's Address(Street,City,5 te,Zip Code): <br /> 7 as YV 1 <br /> IX. COUNTY/ DEPARTME44T USE ONLY <br /> ❑Disapproved Sar Permit Fee tncludesGroundwater ate IssuedIssuing t5ig r tamps) <br /> proved ❑ i_ Surcharge Fee) <br /> Owner Given Initial / (fU <br /> Adverse Determination <br /> . 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 />