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401 <br /> �r (�kq/LklfoSafety and Buildings Division <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> `AIsconsin P O Box 7302 <br /> Department of Commerce In accord with Comm 83.05,Ws.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 8 1/2 x 11 inches in size. <br /> • See reverse side for instructions for completing this application State Sanitary IPPeermit Nu/mmbeerrr <br /> Personal information you provide may be used for secondary purposes ❑Check it r ion previous application <br /> (Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Numbers i <br /> I. APPLICATION INFORMATION- PLEASE PRINT ALL INF RMATI N <br /> Prop rty Owner Name Property Location <br /> N f aG 1/4 1/4,S,?3 T y0 ,N, R /-5-E-(or W, <br /> Property Owner's Mailing Address Lot Number BI�kCNurfbb J / <br /> 4;2 <br /> City,State Zip Code Phone Number Sl�Worilen a e or CSM <br /> �y7o / ( 1Y550 336 V 6 <br /> 11. TY BUILDING: (check one) ❑ State Owned '.t( Nearest Road <br /> ❑ VII age !� 6 <br /> Public 1 or 2 Famil Dwelling-No.of bedrooms own <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber,(s) <br /> 1 ❑ Apartment/Condo 0 / /0 ';z <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. Ig Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> _System ________System ------------- Tank ____________ Existing System ____-___ ExistingSystem <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 DI-Seepage Trench 22❑In-Ground Pressure 42❑Pit Privy <br /> 13❑Seepage Pit ���- /tom^ 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 15. Perc. Rate 6. SystemElev. 7. Final Grade <br /> Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevat <br /> 3e c .17 5 5 7.r , S/ 7 /3 <br /> Feet Y7� io Feet <br /> VII. TANK Capacity Site <br /> in gallons Total #of Manufacturers Name Prefab. Con- Steel Fiber- Plastic Aper- <br /> INFORMATION New Existin Gallons Tanks Concrete strutted glass APP <br /> Tanksl Tanks ` <br /> Septic Tank or Holding Tank <br /> Lift Pump Tank/Siphon Chamber El <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: No Stam s) MP/MPRSWNo.: rBus;inessumber:w s44 �� <br /> Plumb 's Address(Street,city,State,ZipCode): <br /> mZ fi' S`-/`r S !!`e `� G/ She 7. <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sa tary Permit Fee (Ind des Groundwater ate IssuedIssuing A t Si ture(N ps) <br /> ?I�71 <br /> Approved Is- (large Fee) ,�S p� — <br /> C5 pp []Owner Given Initial J ' —/`y—(JtJ <br /> Adverse Determination / <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> DISTRIBUTION: Original to County,One copy To: Safety a Buildings Diumon,Owner,Plumber ' <br /> SBD-6398(R.4/99) __ <br />