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Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> Visconsin 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 �JO/CJQ�Coun <br /> than 81/2 x 11 inches in size. A4,,e, <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> Personal information you provide may be used for seconds 33 o 75 <br /> y p y secondary purposes ❑Check d 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 <br /> Prope y Owner Name s Property Location <br /> 66-cr-t' ��r1�/` S4' 41/4 NUJ 1/4,S .3.3 Tj N, R14 E(or) <br /> Pro <br /> pg rt Owner's Mailing Address Lot Number Block Number <br /> of aoS A;AJ .5 Ao 8 0 k 2 3 <br /> Cit ,State Zip Code 3 Phone Number SubdivisiA" meorCSMNumber <br /> II. TYPE OF BUILDIN(i: (check one) ❑ State Owned ❑ CityVi' Necar�est Road <br /> Public 1 or 2 FamilyDwelling- No.of bedrooms .2 2E Town OF G ¢/�d l r w <br /> III. BUILDINGUSE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo 1 © 333 3 0 ;:2- 700 <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. ❑ Replacement 1 ❑ Replacement of 4. ❑ Reconnection of 5_ ❑ Repair of an <br /> __System ________System ___ _______ TankOnly _____________ Existing System----------Existing System <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 /> 1154 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 5.Perc. Rate 6. System Elev. 7. Final Grade <br /> ? Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) // Elevation <br /> �J 4�'p d W/O D S 6' Feet V. / Feet <br /> Capacity <br /> VII. INFORMATION in altos Total #of Prefab. Site Fiber- Exper_ <br /> g Gallons Tanks Manufacturer's Name concrete Con Steel glass Plastic App <br /> New Existingstrutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank too V006 ❑ ❑ ❑ ❑ 91 ❑ <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: // Plumber's Signature:(No Stamps) MP/MPRSWNo.: Business Phone Number: <br /> / <br /> ,tj4o/te Nrrr f�7d/ el_'?-27Zp// <br /> Plumber's Address(Street,City,pate,Zip Code): or <br /> 4f .�lC/ -5/,-' G✓ S 7� <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> V71 �__ ❑Disapproved SanitaryPermit Fee (includes Groundwater ate ssue Issuing g Sign ure( S mps) <br /> A rovedSurcharge Feel 3—10� <br /> ❑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&Buildings Division,Owner,Plumber <br />