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Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> VAISconsin 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 County <br /> than 8112 x 11 inches in size. 0&lt <br /> • See reverse side for instructions for completing this application State Sanitar Perm t Number <br /> Personal information you provide may be used for secondary purposes ❑Check it revision to previous application <br /> [Privacy Law,s. 15.040)(m)]. State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Propertwner Name P opert Location <br /> OW I LLR/LD -�,/4 1/4,S 2* T N, R 1!; E(or <br /> Property Owner's Mailing Address Lot Number Block Number <br /> O Z 450 4 <br /> City,State Zip Code P�}one Number Subdiviiicn Name o _SM mkcsr <br /> n. E F B L ING: (check one) E] State Owned 'ty~ Nearest Road <br /> ❑ VIl age <br /> Public 1 or 2 FamilyDwelling- No.of bedrooms _ Town of A tJ0 �. <br /> 111. BUILDING E: (if building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo <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. 0 Replacement 3_ ❑ Replacement of 4, ❑ Reconnection of 5. ❑ Repair of an <br /> ------System --------System ------------- Tank Only---------------Existing System----------ExistingSystem <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;0 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 13. Absorp.Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade <br /> Ar,, <br /> Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> "T7V 3 ivis .1 e- 100.4, Feet102.. 7Feet <br /> Capacit <br /> VII. FORMATION in allons Total #of Manufacturer's Name Prefab. Con- Steel glass plastic Aper <br /> New Existin Gallons Tanks Concrete structed glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank QOO 10004+ ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber (QOO ❑ ❑ ❑ ❑ ❑ <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:(Print) Plumber's s Signature:( o S ps) MP/MPRSW No.: Business Phone Number: <br /> 1dkA9V 40PXJ l5 ZZ 1 ?tS- - S <br /> Plumber's Address(Street,City,State,Zip Code): <br /> i-11.o w FB <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> �p ❑Disapproved Sanjt��ry Permit Fee (includes Groundwater ate ssue Issuing A ent Signatur (No Stamps <br /> �I(I <br /> Approved _�-1�//� ��/Q�'rcharge Fee) f ?9 - c`�. <br /> Q` pp ❑Owner Given Initial �f` ��_ <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR'DISAPPROVAL: <br /> SBD-6396(R.4/99) DISTRIBUTION: Original to County,One copy To: Safety a Buildings Division,Owner.Plumber <br />