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CUZ F7(CNp <br /> Safety and Buildings Division <br /> Aseonsin <br /> 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 c2 <br /> than 8 v2 x 11 inches in size. ount " r/t),~ J O 8 <br /> • See reverse side for instructions for completing this application State Sanitary rmifumber�� <br /> Personal information you provide may be used for secondary purposes ❑Check it r n pjk' <br /> wsapplica Ion <br /> [Privacy Law,s. 15.04(1)(m)). State Plan I.D.Nu b r <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION a2 <br /> Pro 7, , 1 va� /7/—d <br /> d� v� 'Prope .Lo4a/4, 4 7 /� <br /> �ty p f✓ v4 vio S T N, R E(o W <br /> P operty Owner's Maili g Addre Lot Number Block Number <br /> ,cpgCity State Zip Code Phone Number Subdivision Name or15M Number <br /> II. T ( IN : (check one) ❑ State Owned !t� Nearest Road <br /> :1 VII age <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms wn of e O <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumbber(s) <br /> 1 E] Apartment/Condo 6r 3/er1614, a�2 C5 <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 3. Replacement of 4. ❑ Reconnection of 5. [:] Repair of an <br /> ___System ___ �ystemE]_____________ TankOnly -____-__ __ ExlstingSyst-- ________ 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 /> 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 Rate15(M <br /> Perc. Rate 6. System Elev. 7. Final Grade <br /> Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) in./inch) �i Elevation <br /> �_, Z d Feet /Feet <br /> VII. TANK Capacity Site <br /> in gallons Total #of Manufacturer's Name Prefab Con_ Steel Fiber- plastic Exper. <br /> INFORMATION New Existing Gallons Tanks Concrete structed glass App- <br /> INFORMATION <br /> Tanks <br /> Septic Tank or Holding Tank (�U ded 1 PSI0 n 0 <br /> Lift Pump Tank/Siphon Chamber © - El 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: rint)nu� � alp Plumber's Signature:(No Sta ps) P��sw� � Busi�Phon�umber. <br /> Plumber's ddress(Street,City,State,Zip Codp: <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disd roved Sanitary P mit Fee (includes Groundwater ate Issuedissuing Ag n ignat a(N t s) <br /> pp Surcharge Feel <br /> proved ❑Owner Given Initial (M�) (� (� <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS OR DISAPPROVAL: <br /> 1e5' <br /> SBD-6398(R.4/99) DISTRIBUTION: Original to County,One copy To: Safety S Buildings Division,Owner,Plumber <br />