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Safy and Buildings Division <br /> Visconsin SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> 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 a35�/ <br /> than 8 12 x 11 inches in size. 405&& , S3 <br /> • See reverse side for instructions for completing this application State SanitaryPer it um ga – �!+ <br /> Personal information you provide may be used for secondary purposes E]Check it revision to previous(application <br /> (Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Num er <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION <br /> Property Owner Nam t / Property Location <br /> P_ /NZ e- c1 1/4 1/4,50 T o ,N, Rjs E(or <br /> Property Owner's Mailing Address Lot Number '91Block Number <br /> /0 o aZ LA-)r -'n //u <br /> City,StateZip Code Phone Number Subdivision Namew QAA Number <br /> `r'w,,j 4.A�kc5 5'31 ? w. 12 )Sr.27_y.7:12 ,Oen/ 7'h <br /> 11. TY BUILDING: (check one) ❑ State Owned ❑ Its Nearest Road <br /> ❑ Village (�Y <br /> Public 1 or 2 Famil Dwellin -No.of bedrooms own OF A s ,tij /4 <br /> 111. BUILDINGUSE: (If building type is public,check all that apply) Parcel TaxNumber(s) G <br /> C? /,;2 91.2 .5' /v <br /> 1 ❑ Apartment/Condo - /0 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.y�New 2. E] Replacement 3. ❑ Replacement of 4. E] Reconnection of 5. [3 Repair of an <br /> __ Syrstem ___System ___ ____ TankOnly_____________ 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 g5eepage 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 IS. Perc. Rate 6. System Elev. 7. Final Grade <br /> Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) _ Elevation <br /> yS0 4 y� 6 VS' 7 — 951 4 Feet 981` Feet <br /> Capacity VII. TANK in gallons Total #of Manufacturer's Name Prefab. Con- Steel Site Fiber- Exper <br /> INFORMATION Gallons Tanks Concrete glass Plastic App <br /> New Existin structed <br /> Tanks Tanks pry <br /> Septic Tank or Holding Tank o0C) le00 s/��9G� ❑ ❑ ❑ ❑ ❑ <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:(Pri t) Plumber's Signature (No Stam s) MP/MPRSW No.: Business Phone Number: <br /> Plumber's Address(Street,City,State,Zip Code): �j <br /> 4 OX � J /` �N e:,J .� O �;2 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved F—y/ <br /> ary Permit Fee (includes Groundwater ate IssuedIssuing ge t Signa rM(Nsl <br /> �A roved —75' s c eFee) <br /> pp ❑Owner Given Initial / <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.4/99) DISTRIBUTION: Original to County,One copy To: Safety a Buildings Division,Owner,plumber <br />