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SANITARY PERMIT APPLICATION Safety w.Washington togs Division <br /> Visconsin � Avenue <br /> Department of Commerce In accord with Comm 83.05,Wis.Adm.Code P O Box 7302Madison,WI 53707-7302 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County �J <br /> than 8 1/2 x 11 inches in size. d5C 3-77 3 <br /> • See reverse side for instructions for completing this application State Sanitary Peym%mber <br /> Personal information you provide may be used for secondary purposes ❑check I s Ito prevlou��application <br /> [Privacy Law,s. 15.04(1)(m)]. <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL IMATION <br /> Property Owner N me Property Location <br /> JT E1A NC, 1/4,532.. T41 ,N, R 1(o E(o W <br /> Property Owner's Maiillin�g Adddss Lot Number Block Number <br /> ;OB� <br /> lY -PIP <br /> Cit ,State Zi Code Phone N tuber Subdivision Name or CSM Number <br /> kku <br /> ow <br /> 11. PE LDIN : (check one) ❑ State Owned ❑ Ity Nearest Road <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms 3 ❑ village StJ(ss �/7 <br /> Town OF coW- D- <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo 032 5332 of +D <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> — <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.X New 2. ❑ Replacement 3. ❑ Replacement of 4. Reconnection of <br /> System 5. E] Repair of an <br /> --_____y ________System Tank_Y ______________ _OnlY______________ Existing System Existing System <br /> ----------------------- <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 Kseepage 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 5. Perc. Rate 6. System Elev. 7. Final Grade <br /> M,� Req fired(sq.ft.) Prop,se(sq.ft.) (Gals/da y/sq.ft.) (Min./inch) Elevation <br /> `L �'TD I ��� Z 9+''I Feet %,$ Feet <br /> VII. TANK Capacity <br /> INFORMATION in gallons Total #of Manufacturer's Name Prefab. Site Fiber- Ex <br /> New Existin Gallons Tanks Concrete con- steel glass Plastic App- <br /> Tanks <br /> T nks Tanks structed <br /> Septic Tank or Holding Tank ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber 13 E 1 � El <br /> Vlll. RESPONSIBILITY STATEMENT <br /> 1,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> 21366- 467 <br /> Plumber'sName:(Print Plumber's Signature: No mps) MP/MPRSWddNo.: 7usinessPhoneNumber: <br /> ��� <br /> PI tier's Address(Stree ity,State,Zip Code) <br /> IX. COUNTY/DEPAKTMENT USE ONLY <br /> DisapprovedudesGroundwater ate Issued pp Si5 itary� ee&rchargeFee) Issuing ge tSignat e(No ps) <br /> pproved []Owner Given Initial <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FORDISAPPROVAL: <br /> SBD-6398(R.4/99) DISTRIBUTION: Original to County,one copy To: Safety B Buildings Division,Owner,Plumber <br />