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3 g 5-'�®lo �bor2/� is <br /> SANITARY PERMIT APPLICATION Safety and Buildings Division <br /> Visconsin 201 E.Washington Ave. <br /> In accord with ILHR 8305,Wis.Adm.Code P.O.Box7969 <br /> Department of Commerce Madison,- WI <br /> WI 53707-7969 <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 N tuber <br /> The information you provide may be used b other government agency programs ��5&�� <br /> Y P Y Y 9 9 Y P 9 ❑Check it revision to previous application <br /> (Privacy Law,s- 15.04(1)(m)]. State Plan I.D.Number ^_ <br /> I. APPLI ATI N INFORMATION - PLEASE PRINT ALL INF RMATION A <br /> Pro ft O�yner Name Property Location <br /> ofj Z 1/0SS 1/4 1/4,S T y0 r N, R / E(ore/ <br /> Property Owner's Mailing Address <br /> rr� ^� Lot Number e Block Number <br /> City,State /!`/Zip Code Phone Number Subdivision Name or CSM Number <br /> GJ c6 6-�.k• y�3� ( 5> �9 757 -- <br /> II. E F BUILDING: (check one) ❑ State Owned ❑ rtVilr Nearest Road A <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms Q i Town OF .5C, y, <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) [� <br /> 1 ❑ Apartment/Condo C a oQ Y/d T O Z �2 O 6 <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 /> S ❑ 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. 20eplacement 3_ ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> ------System ystem __ __--- _ 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 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 /> ® v Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) / Elevation <br /> O O - �- 5� Feet Feet <br /> Capact <br /> VII. TANK in allo s Total #of Prefab Site Fiber- Exper. <br /> INFORMATION New Existin Gallons Tanks Manufacturer's Name concrete Con- steel glass Plastic App <br /> strutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank 15­0 Sd' 1 ❑ ❑ Ej <br /> Lift Pump Tank/Siphon Chamber v �d� �. <br /> Vlll. 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 Signature:( Stamps) MP/MPRSW No.: Business Phone Number: <br /> Plumb r'sAcdress(Street,City,State,ZiRCode): <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> E]Disapproved Sanitary Permit Fee (Includes Groundwater ate IssuedIssuingA a Signpure ps) <br /> Approved [-]Owner Given Initial Surcharge Fee) <br /> Adverse Determination 7S, Oa �y <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.11/96) DISTRIBUTION: Original to County.One copy To: Safety 8 Buildings Division,Owner,plumber <br />