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Safety and BuildingsDivision <br /> W :OflS%D SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> P 0 Box 7302 <br /> D( .nt 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 /> than8 1rz x l l inches in size. e vuL—r <br /> • See reverse sidefor instructions for completiIng thisap c tion State Sanitary Permit Nu b r <br /> 1 COMPUTER/SCAN 8 �� <br /> Personal information you provide may be used for secondary purposes k i rewswn to previous a plication <br /> ]Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Numbs^ <br /> I. APPLICATION INFORMATION- PLEASE PRINT ALL INF RMATION <br /> Propertt Owner Nam p Property Location <br /> A p,# G� va a <br /> 1/4,S /7 T <// ,N, R /S-E(or <br /> Property Own rs Mailing Address Lot Number <br /> ,J'7 WZ� R0 7-7 Block Number <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number /r� � � <br /> �ti� , I ' g� (7/S ) (off- -ilk <br /> It. TYPE OF ILDIN : (check one) ❑ State Owned 0 cit Nearest Road <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms K Town OF SwzsS I s?AlE A1 7 <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo ij 3e;Z <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. E] Replacement 3. E] Replacementof 4. ❑ Reconnection of S. E] Repair of an <br /> ---ystem ---- System - -- Tank Only----------- ---Existln System Existing System <br /> ----Q-Y-------- <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 /> 11VSeepage Bed 21 ❑Mound 30❑Specify Type 41 ❑Holding Tank <br /> 12 ETSeepage 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 1 6. System Elev. 7. Final Grade <br /> 3O,0 Required(sq.ft.) Proposed(sq. ft.) (Gals/day/sq.ft.) (Min./inch) I Elevatiog, <br /> a y 3� r ��-� Feet 991_9 Feet <br /> Ca aclt <br /> VII. TANK in gallons Total #OfPrefab Site Fiber- plastic Exper <br /> INFORMATION New Existln structed <br /> Gallons Tanks Manufacturer's Name concrete Con- Steel glass App <br /> Tanks Tanks A <br /> Septic Tank or Holding Tank SQ Z &,tf� [I 'S 0 El 0 El El <br /> Lift Pump Tank/Siphon Chamber El 11 El 11 Ej <br /> VIII. RESPONSIBILITY STATEMENT <br /> 1,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name:(Print) Plum nature: O S m ) MP/MPRSW No.: Business Phone Number: <br /> -RL L� �26(07e2 77) 2W-35.6 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> (o7/?J S S lL- A-) 5Ylb3O <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved anitary Permit Fee (Indudes Groundwater ate IssuedIssuing Agen S atur N ) <br /> roved /kj fiwge Fee) <br /> PP []Owner Determination* <br /> etermi al /"7� �/ S �7 <br /> Adverse Determination ( / <br /> X. CONDITIONS OF APPLe/REASONS FO�Re tP V ' <br /> k77 <br /> SBD-6398(R.4199) DISTmBUTIOM: original to county,one copy To: safety a Buildings Division,Owner,Plumber <br />