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Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> P O Box 7302 <br /> Asconsin In accord with Comm 83.05,Wis.Adm.Code Madison,WI 53707-7302 <br /> Department of commerce <br /> • Attach complete plans(to the county copy only)for the system,on paper not less county a3331.� <br /> than 81/2 x11 inches in size. State Sanitary PermitNumber <br /> • See reverse side for instructions for completing this application -�3G <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 I.D.Number <br /> I. APPLI ATION INFORMATION- PLEASE PRINT ALL INF RMATIONProperty ocation <br /> Prop y owner Name 1/4 1/4,S T 40 IN, R Itp E(o W <br /> Prop Ownerailin Address — Lot Number Block Number <br /> State Zi Code P e N mber Subdivision Name or CSM Nu ber <br /> r t. DO ( S> <br /> I . PE F IL ING: (check one) ❑ Stat Owned it Nearest Road <br /> �. ❑ Village O„�„ „��ID a <br /> Public 1 or 2 FamilyDwellin -No.of bedrooms own of r-�-c.nrr <br /> III. BUILDINGUSE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo D2D OZ <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 /> Replacement Replacement of 4. E] Reconnection of 5. E] Repair of an <br /> A) 1- El 2 Re p 3. ❑ Tank Only- Existin S stem ExistingSystem <br /> System System ------------------ -y----------------- -y---- <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 C]Mound 30 E]Specify Type 41 [:]Holding Tank <br /> � <br /> 12❑Seepage Trench 22❑In-Ground Pressure 42 C]Pit Privy <br /> 13 E]Seepage Pit 43 E]Vault Privy <br /> 14❑System-In-Fi II <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.) Pro o ed sq.ft.) (Gal/day/sq.ft.) (Min./inch) EI ation <br /> 1_ �S•3 Feet _O Feet <br /> VII. TANK Capact Site <br /> in gallons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. <br /> INFORMATION New Existin Gallons Tanks Concrete strutted glass APP <br /> Tanks Tanks ❑ <br /> Septic Tank or Holding Tank Zi2w ❑ El ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plu bar's Name:(Prin Plumber's Signature: No mps) MP/MPRSW No.: Business Phone Number: <br /> 22 S$ l5'- U-41-57 .. <br /> PI umber's Address(Street,City, te,Zip Code): <br /> 2-'i 6 o w 3S <403 <br /> IX. OUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee (includes Groundwater Fat�essuedIssuingA nt S=77 <br /> ❑ pp surcharge Fee) �n Approved ❑Owner Given Initial —/rf 'V V <br /> Adverse Determination <br /> X. C NDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> DISTRIBUTION: Original to county.One copy To: Safety&Buildings Division,owner,plumber <br /> SBD-6398(R.4199) _----.—____----------_._ <br />