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Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> Visconsin P O 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 <br /> than 8112 x 11 inches in size. a t1 <br /> See reverse side for instructions for completing this application State Sanitaryrr0itNum /7( XJ <br /> Personal information you provide may be used for secondary purposes ❑Check if r6lilion to previous application <br /> [Privacy Law,s. 15.04(1)(m)). State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF ORMATI N <br /> Prope y Owner Name Property Location / <br /> 1/4 1/4,S f6 T�f6 ,N, R/G E(or <br /> Property Owner's Mailing Addr s Lot Number Block umber <br /> O14� A& <br /> City,State I Zip Code Phone Number Subdivision Name or CSM Number <br /> ,4r,--de,r `G � S ( )3.27-513W ,4 4 ti d <br /> 11. TYPEI DING: (check one) ❑ State Owned ° City `` rN;ea.re!stRoadPublic 1 or 2 Famil Dwellin -No.of bedrooms ° Town of � kI4^1r� �M S>L�� <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 0`d0- <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. Q Replacement 3. Q Replacement of 4. Q Reconnection of 5. Q Repair of an <br /> -__--' System ____--_-System ------------- --__________-- _-_--___Tank OnlyExisting 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 ❑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 Q 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) Q Elevation <br /> SD 3 y t 7 i /� Feet A6„ '1 Feet <br /> TANK Capact Site <br /> VII INFORMATION in allons Total #of Manufacturer's Name Prefab. Con- steel Fiber- Plastic Exper <br /> New Existin Gallons Tanks Concrete structed glass App. <br /> Tanks Tan ks <br /> Septic Tank or Holding Tank BOO 000 l !'�L <br /> AV---j 9 ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ 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 <br /> Plumber's Signature:(No Stamps) MP/MPRSWNo.: Business Phone Number: <br /> G�Ad_A_ �4 tio/ <br /> Plumber's Address(Street,City,State,Zip Code): <br /> OX / i%`G.v GJ j _-5” 8 7�- <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> XOwne❑Disapproved Sa tary Permit Fee (Includes Groundwater ate IssuedIssuing Ag t Signature(No Stamps) <br /> pproved ❑ (^ surcharge Fee) 5+oo <br /> r Given Initial 5� J <br /> Adverse Determination <br /> . CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.4/99) DISTRIBUTION: Original to county.One copy To: Safety&Buildings Division,Owner,Plumber <br />