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Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> P O Box 7302 <br /> isconsin In accord with Comm 83.05,Wis.Adm.Code Madison,WI 53707-7302 <br /> Department of Commerce <br /> � Attach complete plans(to the county copy only)for the system,on paper not less County c7_378 <br /> than 81/2 x 11 inches in size. to Sanitary Permit Number <br /> • See reverse side for instructions for completing this application 36� p S-ib <br /> ❑ us application <br /> Personal information you provide may be used for secondary purposes Check it revision to prev <br /> State Plan I.D.Number <br /> (Privacy Law,s. 15.04(1)(m)]. <br /> 1. APPLI ATI N INFORMATION -PLEASE PRINT ALL INF RMATIIONpert ocation <br /> Prope Owner Nary /4 1/4,S u T N,R Ito E(o W <br /> aDy�L t Lot Number Block Number <br /> Prope Owner' Mailin Address a. <br /> City,State ''__II Zi Code Phone Number Subdiytp n Name or CSM Number <br /> P- ( ) ❑ Ity Nearest Road <br /> I B LD NG: (check one) ❑ State Owned ❑ village S �OI�ER <br /> Town OF S <br /> Public 1 or 2 Famil Dwellin -No.of bedrooms Parcel TaxNumber(s) <br /> 111. BUILDING USE: (If building type is public,check all that apply) � Z 030 <br /> 1 ❑ Apartment/Condo 10 C] outdoor Recreational Facility <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/NursingHome 11 ❑ Restaurant/Bar/Dining <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 12 ❑ Service Station/Car Wash <br /> 4 ❑ Church/School 8 ❑ Mobile Home Park 13 ❑ Other: specify <br /> 5 ❑ Hotel/Motel 9 ❑ office/Factory <br /> IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B,if applicable) Repair of an <br /> Re lacement of 4. Reconnection of 5. ❑ is . <br /> A) 1 � New 2 E] Replacement 3. ❑ p ❑ Existing S stem -Existing System <br /> System Tank Onl _--- -y_----------- <br /> ------System _--------Y------------------------�----------- <br /> B) ❑ A Sanitary Permit was previously issued. Permit Number <br /> Date Issued <br /> V. TYPE OF SYSTEM: (Check only one) Experimental Other <br /> Non-Pressurized Distribution Pressurized Distribution p 41 Holding Tank <br /> 11 PQ Seepage Bed <br /> 21 ❑Mound 30❑Specify Type ❑ <br /> 42❑Pit Privy <br /> 1 ❑Seepage Trench 22❑In-Ground Pressure 43❑Vault Privy <br /> 13[]Seepage Pit <br /> 14❑System-In-Fill <br /> VI. ABSORPTION SYSTEM INFORMATION: <br /> Elevation <br /> 1.Gallons Per Day 2. Absorp.Area pro Proposed(sq.ft.) (Gals/day/sq.gft) (M nr/incc. hje 6. System Elev. 7. Final Grade <br /> 6 08,2- Feet <br /> Req ired(sq. ) Z M--�- q�. Feet <br /> 3va q ' <br /> Capacity Site Fiber- Exper. <br /> VII. TANK Total #of r Prefab. Plastic App <br /> in gallons Gallons Tanks Manufacturer's Name concrete strutted steel glass <br /> INFORMATION New Existin <br /> Tank Tanks ' R ❑ ❑ ❑ ❑ ❑ <br /> Septic Tank or Holding Tank ❑ ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber <br /> Vlll. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage <br /> ew nailgesystem Noshown on�th the Phoned pubes <br /> Plumber'sName:(Print) Plumbeissignatur ( Stamps) ZZ�S9( It5-942Zzo, s <br /> Plu ber'ssAddress(street,Cit.state,zi Code):/ <br /> 2.•,1 T"tl7 <br /> IX. COUNTY/DEPA TMENT USE ONLY <br /> Itary Permit Fpm OndudesGroundwater ate ssue� Issuing A e Signa ur S amps) <br /> [I Disapproved ^ Sar(harge Fee) // <br /> �,4�proved ❑Owner Given Initial / /U�J�) <br /> Adverse Determination ` <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> DISTIIIBUTIDN: Original to County.One copy To: Safety&Buildings Division,Owner,Plumber <br /> SBD-8398(R.4199) <br />