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Safety and Buildings Division <br /> ` A TARY PERMIT APPLICATION 201 W.Washington avenue <br /> isconsi P O Box 7302 <br /> Department of comme ce In accord with Comm 83.05,Wis.Adm.Code Madison,WI 53707-7302 <br /> • Attach complet pla the co y copy only)for the system,on paper not less county //� <br /> than 8112 x 11 in hes in size. ti �f <br /> • See reverse side fo Ions for completing this application State Sanitary Permit Number./{ <br /> Personal information you provide may be used for secondary purposes ❑check it revision to rev"ious�pplicalion <br /> [Privacy Law,s. 15-04(1)(m)] StatePlan I.D.Number <br /> I. APPLICATION INFORMATI N - PLEASE PRINT ALL INF RMATI N �— <br /> Property Owner Name , Property Location ,,�� <br /> u/ $ TOC- Iia t/a,5 .23 T Y6 N R /5—E(Of�J <br /> Prop y Owner's Mailing Address Lot Number Block Number <br /> — <br /> City,�tate Zip Code Phone Number S n Na a or CSM Number <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ City Nearest Road <br /> ❑ Village � ly //�� <br /> Public or 2 FamilyDwelling-No.of bedrooms 3 Town OF /t <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Numbeerr,(ss)) <br /> 1 ❑ Apartment/Condo 0l� 13 foo <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/Mote[ 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. I5i New 2. ❑ Replacement 3. ❑ 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 (EI-Seepage Bed 21 ❑Mound 30❑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. Fina[ Grade <br /> �S� Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) q� Elevation <br /> 9�U �4 U i j / �i Feet Feet <br /> act <br /> VII. TANK in Cap <br /> gallons Total #of Prefab. Site Fiber- Exper. <br /> INFORMATION Gallons Tanks Manufacturers Name concrete con- Steel glass Plastic App <br /> New Existin strutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank I, ❑ ❑ I ❑ 1 ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ 1 ❑ I ❑ ❑ <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) Plumber's Signature:(No Stamps MP/MPRSWNo.: Business Phone Number: <br /> Plumber's Address(Street,City,State,Zrip Code): <br /> �o jC �l .Sl/t e iv �itJ� S" X72 <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved S y Per it Oncludes Groundwater ate Issued <br /> ssuing A n ign t re a ps) <br /> proved �� ge Fee) <br /> ❑Owner Given Initi <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.4/99) DISTRIBUTION: Original to County.One copy To: Safety 8 Buildings Division,Owner,Plumber <br />