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Safety and Building <br /> Viicliiiiinsin 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 ('� t <br /> 0 Attach complete plans(to the county copy only)for the system,on paper not less County J// -� <br /> than 81/2 x 11 inches in size. 1!l!''n fT I o o <br /> • See reverse side for instructions for completing this application State Sanitary Number <br /> Personal information you provide may be used for secondary purposes ❑ i� <br /> Check ision to prioud"'tion <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION y <br /> Pr erty0erName P open Locationvo P/1,14 ,�� <br /> 1:::"/Z 14 ,e-r 111i.1 gi i4 1 d/4,S 3 T ,N, R 1.7 4i4"(D <br /> Property Owne s Mailing Addre Lot Number Block Number <br /> I SC7I SS <br /> Cit State r Zip Code Phone Number Subdivision Name or CSM Number <br /> C,et St;aate r <br /> syry 71 0111111-2 <br /> II. TYPE OF BUrt:DING: (check one) ❑ State Owned 'ty Nearest RD d <br /> ❑ Village // / <br /> Public 1 or 2 Family Dwelling-No.of bedrooms -.2, Town OF !tel viLOl GYt <br /> III. BUILDING USE: (If building type is public,check all that apply) ParcelTax Number(s) <br /> 1 ❑ Apartment/Condo 1 & _31/33 0 0O <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 /> S ❑ 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. 9New 2. ❑ Replacement 3. E] Replacementof 4, ❑ Reconnection of 5. ❑ Repair of an <br /> System _ _ System ------------- Tank Only 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 /> 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 15. Perc. Rate 6. System Elev. 7. Final Grade <br /> �� Required(sq.ft.) Propos(Z ft.) (Gals/day/sq.ft.) (Min./inch) p/ Elevation <br /> -/6. © Feet Feet <br /> Capout <br /> VII. FORMATION in allons Gaollons Tanks co�c Prefab. <br /> Site Fiber-ass Plastic APpr. <br /> Manufacturer's Name Con- Steel <br /> New Exi nke structed <br /> Tanks Tanks (fir <br /> eptic Tan or Holding Tank X l r IL7 ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibi ity for installation of the onsite sewage system shown on the attached plans. <br /> P u tier's Name:(Pri t) Ptu tier's Signat e' o Stamps) MP/MPRSW No.: Business Phone Number: <br /> 2 S 2 h Z-Z-C-zz at / �6- <br /> Plumber's Address(5 reet,City,State,Zip Codg): <br /> IX. COUNTY/DEPARTMIENT USE ONLY <br /> 11 Disapproved S ary Permit Fee (Includes Groundwater ate IssuedIssuing nt Sign re(N St ps) <br /> Approved E]Owner Given Initial skrchargeFee) J <br /> Adverse Determination GTC� <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-8398(R.4/99) DISTRIBUTION: Original to County.One copy To: Safety&Buildings Division,Owner,Plumber <br />