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Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> N*Lc6nsin In accord with ILHR 83.05,Wis.Adm.Coe P O Box 7302 <br /> Code Department of Commerce Madison,WI 53707-7302 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County <br /> than 8 112 x 11 inches in size. R4r CF <br /> • See reverse side for instructions for completing this application State Sanitary mitit Number <br /> Personal information you provide may be used for secondary purposes ❑Check it revision to previousapplicationr <br /> (Privacy Law,s. 15.04(1)(m)]. -+ <br /> State Plan I.D.Num 07�/3 <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATI N <br /> Property Owner Name Propert Location <br /> k" WW 1/4, :jr T Z/0,N,RI6 E(or>Qi <br /> Property Owners Mailing AddressLot Number Block Number <br /> J•737/ E. Zaj Uc �� 6.:vf. 4ar <br /> City,SW <br /> Zip o e Phone Number Subdivision Name or CSM Number <br /> e6 >�Jer, ip4e 3 (;, 6-�a <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned oCity Nearest Road /� <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms 3 &rowan OF IQW 1G/J¢� �cdh� R <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo rr 0J-0` 4 335"— 0 3-461*1 <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. W New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> ___System ___ ___System ------------- Tank Only _______ Existin�Sy---stem -------_ Existin-----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 /> 11 ❑Seepage Bed 21 VQ 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 /> 7. Gallons Per Day 2. Absorp.Area3. Absorp.Area 4. Loading Rate 5,Perc. Rate 6. System Elev. 7. Final Grade <br /> Required(s9.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> 4151-0— Feet 100/ Feet <br /> TANK <br /> Capaclt <br /> VII. INFORMATION in gallons Total #of Manufacturer's Name Prefab. Site Con- steel Fiber- Plastic Exper. <br /> New Existin Gallons Tanks concrete strutted glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank WO 1 1 low iff .5'/1ese u-- © ❑ ❑ El 1:1 1:1Lift Pump Tank/Siphon Chamber 6W 1 1 a ES ❑ ❑ ❑ ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> 1,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name:(Print) PI er'ssignature: No mps) MP/MPRSWNo.: Business Phone Number: <br /> IG o z�58s1 S-0 - 5 <br /> P m tier's Address(S reet,City,State, ip Code): <br /> 77 3S I <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapprovedsa�ptltaryPermitFee (IndudesGroundwater ate IssuedIssuing ntSi t Stamps) <br /> Approved F1 Owner Given Initial 111 /Surcharge Fee) / <br /> Adverse Determination `1[ ,001 `^' <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.11/97) DISTRIBUTION: Original to County.One copy To: Safety&Buildings Division,Owner,Plumber <br />