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Safety and Buildings Di <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> !,epr!arsconsin P O Box 7302 <br /> tment of Commerce In accord with Comm 63.05,Wis.Adm.Code Madison,WI 53707-7302 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less cD v /la <br /> than 8 1/2 x 11 inches in size. CL <br /> • See reverse side for instructions for completing this application St a Sanitary PermiiittNumber Z <br /> Personal information you provide may be used for secondary purposes ❑Check if revision to previous application <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan LD.Number �. <br /> I. APPLICATION INFORMATION- PLEASE PRINT ALL INF RMATION <br /> Prope Owner Na Property Location h /� / <br /> AN 1/4 1/4,S 10 T40 ,N, R (4 E(or <br /> Prope'Kwner's Mailinji.,Address �— Lot Number r <br /> City,State Zi e / P ne N tuber Subdivision Name or CSM Number <br /> P_ sss <br /> II. P BUILDING: (check one) ❑ Sta a Owned Vit( Nearest Road <br /> ❑ VII age <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms Town of _ Eqr <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo 02-S 4110 03 Soo <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�Rep[acement 3. ❑ Replacement of 4_ ❑ Reconnection of 5. ❑ Repair of an <br /> System _-_ System --_ Tank Only <br /> ---------------Existing System __ _ ExistingSystem <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 Per Day 2. Absorp.Area 3. Absorp.Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade <br /> 300RequireZ�q.ft.) Proposed(sq. <br /> .S(sq.ft.) (Gals/day/sq.ft.) (Min./inch) levation <br /> �1 61-7. Feet 00.0 Feet <br /> VII. TANK Caaclt <br /> in gallons Total #of M 's Name Prefab. con- Steel Fiber- plastic Aper <br /> manufacturer's INFORMATION New Existin Gallons Tanks Concrete strutted glass App <br /> nks Tanks <br /> Septic Tank or Holding Tank <br /> Lift Pump Tank/Siphon ChamberTapot 1] ❑ El <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> PI ber's Name:(Print I Plumber's Signature:( St ps) MP/MPRSWNo.: Business Phone Number: <br /> SAA ww,✓3 22S�S v �o- <br /> umber's Address(Street,City, tate,Zip Code): <br /> 27760 t. 3 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Salititary Permit Fee ndudes(;roundwater ateslue Issuing a Sign ore( amps) <br /> Approved F1Owner Given Initial �// rcharge Fee)Adverse Determination / <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> DISTRIBUTION: Original to County.One copy To: Safety&Buildings Division,Owner,Plumber <br /> SBD-6398(R.4/99) <br />