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Safety ana Buildings Divi ion <br /> SCOnS�n 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 County <br /> than 81/2 x 11 inches in size. a i- rl t re- T / <br /> • See reverse side for instructions for completing this application State Sanitary <br /> Permit Neuumbberr (� <br /> Personal information you provide may be used for secondary purposes C]Chec�evTsi re4iou application 1 <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Numbed / \ <br /> I. APPLICATION INFORMATION- PLEASE PRINT ALL INF RMATION <br /> Property OwnerName Prgperty Location <br /> ?h�, S Ale/4 S w 1/4,S / 7 T 44 / ,N, R /S—E(or <br /> Property Owner's Mailing Adcrress Lot Numberer Block Number <br /> 3 / ra uGlJr• <br /> Cit,y,State Zi Code Phone Number Subdivision Name or CSM Number <br /> Urn u N �(/_ k:Ir D 1( > cS h-r v r 7 <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned C] ty Nearest Road <br /> E] To age Swis S T <br /> 171 Public 1 or 2 FamilyDwelling-No.of bedrooms _� Town of 4.bor G Qr <br /> III. BUILDINGUSE: (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/Mote[ 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. p.Replacement 3, E] Replacement of 4_ E] Reconnection of 5, [:] Repair of an <br /> System -___- System -- _ ____ __ Tank 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 $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 5. Perc. Rate 6. System Elev. 7. Final Grade <br /> LRequired(sq.ft.) Pro osed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) G� Elevation <br /> KSD 61V Y;g + I 5 /" Feet '/(it.5� Feet <br /> Capacit VII. FORMATION in llons Total #of Prefab. Site Fiber- Exper- <br /> g Gallons Tanks Manufacturers Name Concrete Con- steel glass Plastic App <br /> New Existin strutted <br /> Tanks Tanks rQ <br /> Septic Tank or Holding Tank 000 51ex Iw ❑ ❑ <br /> ❑ftPump Tank/Siphon Chamber ❑ El El ❑ 0 0 <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) Plum s S gnature:( St ps) IMP/MPRSW NQ.: Bu-siinness Phone Number: <br /> /L <br /> P mber's Address(Street,City,State,Zip Code): <br /> *.774o f/µ. 3S" N/ <14r 3 <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved S itary ermitFee (IndudesGroundwater ate ssue Issuing gen Signat mta <br /> �Bpiproved ❑OwnerGiven Initial �,/ 3 nargeFee) 6 <br /> Adverse Determination ` . J <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.4/99) DISTRIBUTION: Original to County,One copy To: Safety a Buildings Division,Owner,Plumber <br />