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V <br /> `� 3aT an ildings Division <br /> ` sconsin SANITARY PERMIT APPLICATION 201 W.pOBox Washington Avenue <br /> 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 Count / a 3 / //h <br /> than 8 v2 x 11 inches in size. T 611 Ri <br /> • See reverse,side for instructions for completing this application State Sanitary Perr(mit Num!Ler <br /> Personal information you provide may be used for secondary purposes ❑Check if reOn`Yo previous application <br /> (Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION <br /> Pr qy Owner Na Property Location <br /> (C a )•r-e lUW1/4 PWt/4,S 3(A T �0 rNrR <br /> Property Owner's Min Address Lot NumberBlock Number <br /> i'h, k- G� >1e LcJ <br /> City;State Zip Code Pone Number Su division Name or CSM Number <br /> USS�o VV►v>. SSS6 (�(2) 712 GOV t Sm Vol l {� 2q <br /> II. TYPE OF—BUTIOLDING: (check one) ❑ State Owned El City Nearest Road > <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms 5 Iowan OF Q S� P N A1$��4 ( I V-e <br /> III. BUILDING USE: (if buildingtype is public,check allthatapply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo I <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 /> S ❑ 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. M Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> ------System --------System --------_ __ TankOnly__________ _ 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 /> 11 []Seepage Bed 21 ❑Mound 30❑Specify Type 41 ❑Holding Tank <br /> 12 1ZSeepage Trench 22❑In-Ground Pressure 42❑Pit Privy <br /> 13❑Seepage Pit 43❑Vault Privy <br /> 14❑System-In-Fill 7-S — Sl ae w a Kc er T_tv 14-ra}ors <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 /> 3 00 37 S 3 , �Z 0 Feet p Feet <br /> Ca acct <br /> VII. TANK in g Ido s Total #of Prefab. Site Fiber- Exper <br /> INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel lass Plastic App <br /> New Existingstructed g <br /> Tanks I Tanks <br /> Septic Tan or Holding Tank K SO Gt/(Ld$2F' ® ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon ChamberII <br /> El El El El 1:1 1:1 <br /> Vill. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name:( rin Plu ber'sSignatue: Stamps) MP/MPRSWNo.: Business Phone Number: <br /> (S oer ✓ zz.szZ17/1- <br /> Plumber's Address(Street,City, ate,Zip Co e): <br /> s � <br /> IX. <br /> tfv-e6s�r c,�rr � 3 <br /> COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (IndudesGroundwater ate IssuedIssuing Age Sign ure amps) <br /> pproved ❑Owner Given Initial hargeFee) L/ ,,��yy�� <br /> 1 f <br /> Adverse Determination / y�W <br /> X. CONDITIONS OF APPROVAL/REASONS FORDISAPPROVAL: <br /> SBD-8398(R.4199) DISTRIBUTION: Original to County,One copy To: Safety 8 Buildings Division,Owner,Plumber <br />