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�f a d Buildings Division <br /> Visconsin SANITARY PERMIT APPLICATION 201 W Washington Avenue <br /> P O Box 7162 <br /> Department of Commerce In accord with Comm 83.05,Wis.Adm.Code Madison,WI 53707-7162 <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 Permit Number <br /> ,3(0c2t77o2 <br /> Personal information you provide may be used for secondary purposes ❑Check it revision to previous application <br /> [Privacy Law,s. 15.04(1)(m)1. <br /> State Plan Review Transaction Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATI N �a <br /> Property Owner Namer y Location <br /> Q , `1/Qr 1/4 1/4,S z j T 3 �7,N, R Ig' E(or)42 <br /> Propgay wner'sMailing Address � Lot Number Block Number <br /> Ci tate / Zip d Ph ne Nu ber Subdivision Name or CSM Number <br /> rum dur 4/. � d (moi/s> �`6� <br /> III. TYPE OF B ILOING: (check one) ❑ State Owned " !t� f /� Nearest Road l <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms _ S ❑Town OF 7 ae C,40f,: I` /�d <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo O 3� Z Cr 'C>Z —�ab <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 online B,if applicable) <br /> A) 1. ❑ New 2. X Replacement 1 ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> ____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 /> 11 ❑Seepage Bed 21 ❑Mound 30❑Specify Type 41 M 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 /> 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.) (Galsiday/sq.ft.) (Min./inch) Elevation <br /> ^ I Feet Feet <br /> 1.Gallons Per Day <br /> TANK Capac <br /> VII INFORMATION in allons Total #of MfPrefab. Con Fiber- plastic Exper. <br /> Manufacturer's Name <br /> New Existin Gallons Tanks Concrete Steel glass App. <br /> Tanks T nk structed <br /> Septic Tank or Holding Tank Q ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber El 1:1 ❑ ❑ 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 /> Plum 's Name:(PJr nt) Plumb 's Signa re: Stamps) MP/MPRSW No.: Business Phone Number: <br /> D�Jc°J T cc r <br /> Plu er's Address(Street,City,State,Zip Code) <br /> .3`'70. S7 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> E]Disapproved Sanitary ermit Fee (InclucietGroundwaler a e-issuedIssuing gent Signature(No Stamps) <br /> Approved C]Owner Given Initial - -7S surcharge Fee) <br /> Adverse Determination <br /> o0 <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.12/99) DISTRIBUTION: Original to County.One copy To: Safely&Buildings Division,Owner,Plumber <br />