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Safety and Buildings Division <br /> �+ <br /> � SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> Wisconsin In accord with 83.05,Wis.Adm.Code P O Box 7302 <br /> h I <br /> 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 1/2 x 11 inches in size. <br /> • See reverse side for instructions for completing this application STate sanitary P mi tuber <br /> Personal information you provide may be used for secondary purposes E]Chec�i on to previous application <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Numb <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATI N <br /> Property wner Name Prop y oc tion <br /> 4 /4,S j4 T N, R 4 E(or)(W <br /> Property wn is ailingTress dress Lot Number Block Number <br /> City,State Zip Code - Phone Number Subdivision Name or CSM Number <br /> J 2b ( 05 2.36 <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ° v nage Nearest Road <br /> Public 10 1 or 2 Family Dwelling-No.of bedrooms Town OF lie <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo 022 411+ Q2tX)Q <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. E] Replacementof 4. [:] Reconnection of 5_ E] Repair of an <br /> ____T' 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 /> I V 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-I n-Fi I I <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 /> 30 04S;7— .7 �� q,+.55- <br /> ) <br /> 4.S5 Feet $-0 Feet <br /> Ca cit <br /> VII. TANK in gallons Total #of Prefab. Site Fiber- Exper. <br /> INFORMATION New Existin Gallons Tanks Manufacturers Name concrete Con- steel glass Plastic App <br /> strutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank R El El F1 Ej El <br /> Lift Pump Tank/Siphon Chamber U ❑ El ❑ ❑ 11 <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 Signature'(N tamps) MP/MPRSW No.: Business Phone Number: <br /> I[F}f}IG1►� 2.2585 $- - <br /> PI tuber's Address(Street,City,Stat Zip Code): _ <br /> 26j63f:rjZ W) <br /> IX. COUNTY/DEPARTM ENTJUSE ONLY <br /> ❑Disapproved Sanitary Permit Fee (includes Groundwater ate Issued Issuing A Signa a(N PS) <br /> roved (J kurcharge Fee) ) <br /> pp ❑OwnerGivenInitial ,7�f <br /> Adverse Determination Cry lv G <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 />