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Safety andBuilding <br /> ` sconsin SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> P O Box 7302 <br /> Department of Commerce In accord with Comm 63.05,Wis.Adm.Code Madison,WI 53707-7302 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less CgUnty <br /> than 81/2 x 11 inches in size. `! <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 it revision to previous application <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number ` <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION I !/IV/ <br /> Prope Owner Naa Property Location <br /> �� 1/4 1/4,S 6 T N, R E(o W <br /> Property Owner's Mailing Address Lot Number r <br /> ' — <br /> CState Zi Code P ne Number <br /> it ,Aug6aSubdivision Name or CSM Number <br /> ( 11 S�4-027- 2S- <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ CIty Nearest Road <br /> C] Village <br /> Public 1 or 2 Famil Dwellin -No.of bedrooms 2 Town OF _73- 9Q. C <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo iQ12 vto LO) **Zoo <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 online B,if applicable) <br /> A) 1. g New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> - _System _ System ___ __ Tank Only - ExistingSystem __-__ _ Exi sting <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❑System-In-Fill <br /> VI. ABSORPTION SYSTEM INFORMATION: <br /> 1.Gallons Per Day 2. Absorp.Area 3. Absorp.Area 4. Loading Rate S. Perc. Rate 6. System Elev. 7. Final Grade <br /> Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> AV1--ollill ,'� 0 — -Z Feet .5 Feet <br /> VII. TANK Capacityin aIIO S TOtal #Of Prefab. Site Fiber- Exper <br /> INFORMATION g Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App <br /> New Existin structed <br /> T nks Tank <br /> Septic Tank or Holding Tank To I 'rte M n 1:1 ❑ ❑ <br /> LlftPumpTank/SiphonChamber ❑ i 1:1 ❑ ❑ 1:1 E] <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 Plumber's Signature:(No amps) MP/MPRSW No.: Business Phone Number: <br /> 4}At+� f71Jf !_'LS S- - <br /> PI tuber's address(Street,City,Sta e,Zip Code): <br /> �- <br /> IX. COUNTY/DEPARTMEW USE ONLY <br /> ❑Disapproved Sa to/]ryPermitF a (Includes Groundwater ate ssue Issuing g `tSign r s) <br /> L 7� Sur<harge Fee) �� <br /> proved ❑Owner Given Initial 19 <br /> Adverse Determination <br /> X. CONDITIONS OF APPROV L/REASONS FOR DISAPPR0 L: <br /> �9�j <br /> 71 <br /> SBD-6398(R.4/99) DISTRIBUTION: Original to county.One copy To: Safety Buildings Division,Owner,Plumber <br />