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vision <br /> A M SANITARY PERMIT APPLICATION Safety and Buildings Di <br /> �. 201 W.Washington Avenue <br /> `8SCOIIsin P O Box 7302 <br /> Department of Commerce In accord with Comm 83.06,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. e wvl_-,� <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> Personal information you provide may be used for secondary purposes Check I revlslon to previous a5plication <br /> [Privacy Law,s. 15.04(1)(m)]. <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION <br /> Property Owner Namgg Property Location <br /> 114 L o_A 2 $ t-147.0(1 - vl-7)L" 6'k 1/4 a 1/4,S /Z T L/l ,N, R /5-E(or <br /> Property Own is Mailing Address Lot Number Block Number <br /> 67 1) 7& R-0 7-7 <br /> City,State Zip CodePhone Number Subdivision Name or CSM Number /D G{2j=� <br /> (7S- > loS�-3!� <br /> II. TYPE BUILDING: (check one) E] State Owned [Iity Nearest Road <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms ° Iowan OF SS �'7ATE 7 <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo c 3�?, <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.)a(New 2. ❑ Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5. ❑ Repair of an <br /> ystem 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 E]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(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) e / /. Elevatioq/ <br /> 3Oo y�a r �— /2 Feet �/'`/ Feet <br /> TANK Ca gallons actSite <br /> VII. INFORMATION ..Cap <br /> n gTotal #of Manufacturer's Name Prefab. Con- steel Fiber- plastic Exper. <br /> New ExistingGallons Tanks Concrete strutted glass App. <br /> Tanks Tanks /� 2U1 <br /> Septic Tank or Holding Tank 7S� -- 5'D I �G �� J ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ ❑ <br /> Vlll. 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 nature:INo S m ) MP/MPRSW No.: Business Phone Number: <br /> �2z(ell lo7627/i 7) 741-3Sd <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 14,-7/-5 S- S &F_ A-) <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved anitary Permit Fee includes Groundwater ate IssuedIssuing Agen Si atupl:;X� <br /> 4pproved ❑Owner Given Initial 7,5 �r`hargeFee) c- , <br /> Adverse Determination ( J ` 4 <br /> -001 <br /> X. CONDITIONS OF APPR VAL/REASONS FOR ,IIS/APPROVAL: <br /> SBD-6398(R.4/99) DISTRIBUTION: Original to County.One copy To: Safety a Buildings Division,Owner,Plumber <br />