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Safety and Buildings Division <br /> ASANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> sconsin 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 8 1/2 x 11 inches in size. <br /> • See reverse side for instructions for completing this application StiMe Sanitary Perm it Number <br /> Personal information you provide may be used for secondary purposes ❑Check if ree'Z'f42us appl tcation <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Numb{ <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION IL� <br /> Property Owner Name Property Location <br /> 1/4 1/4,5 OT T N, R IS E(or <br /> Property Owner' Maiin Address Lot Number Block Number <br /> Cily,State Zip Cyy�de Phone Number Subdivision Name or CSM Number <br /> 5025 ( 44 <br /> -276& DI'n <br /> 11. TYPE F B IL Ix. NoING: (check one) ❑ State Ownedit� Nearest Road <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms 3 °Town o <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo 0)C-�"- q10 ^0/—J <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. j< New 2. ❑ Replacement 3_ ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> ------System --------System ------------- Tank Only--_-_---_____ Existing System..........ExlstingSystem <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 /> 11Seepage Bed 21 E]Mound 30 E]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 PerDay 2. Absorp.Area 3. Absorp.Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade <br /> A^�,O Re uired(sq.ft.) Pro osed(sq.ft.) (Gal ay/sq.ft.) (Min./inch) p Elevation <br /> J $ �~� 1�•7 Feet �i.� Feet <br /> Capacct <br /> VII. INFORMATION in Ilons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Exper. <br /> Gallons Tanks concrete glass Plastic App <br /> New Existin strutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank I ❑ ❑ ❑ ❑ ❑ <br /> LIR Pump Tank/Siphon Chamber El ❑ ❑ ❑ ❑ ❑ <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) Plumber's Signatua( tamps) MP/MPRSW No.: Business Phone Number: <br /> U{*o ld$ l 110- 96- <br /> P145mber's Address(Street, ity,State,Zip Cod <br /> 77 �JI. q <br /> IX. COUNTY/DEPAKTMENT USE ONLY <br /> ❑Disapproved Sanitar Permit Fee (includes Groundwater [ateIssuing Agent Signature(No tamps) <br /> roved Surcharge Fee)pp ❑Owner Given Initial � ��Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.4/99) DISTRIBUTION: Original to County.One copy To: Safety&Buildings Division,Owner,plumber <br />