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cr)/� e <br /> afety and Buildings Division <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> Owasin P O Bax 7302 <br /> Departmen of Commerce In accord with[LHR 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 St to Sanitarrryy(Permit Number <br /> Personal information you provide may be used for secondary purposes E]Check revi'cion t0evi1s application <br /> [Privacy Law,s. 15.04(1)(m)]- State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFO RMATI N /L <br /> Prope54 Owner Name Property Location <br /> -KA UP 14 LI 1/4 1/4,S 13*7,JT ,N, R ;E(or W <br /> Prope y Owner's Mailing Address Lot NtLmber 3 <br /> D ((J-5 VD 230 +- <br /> City,State Zip Code Phone Number Subdivision Name or Mo ber <br /> 14 �i"a ( I2)S -6 7 Jam• 13 T. - 146 <br /> YP B DIN : (check one) ❑ State Owned !t� Nearest Road <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms _Z Town OF ::�AG tf <br /> III. BUILDIN USE: (If building type is public,check all that apply) Parcel TaxNumbbeer(s) <br /> 1 ❑ Apartment/Condo r o <br /> 2 ❑ Assembly Hall 6 ❑ Medica[ 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. (7d Replacement 3. ❑ Replacement of 4. ❑ Reconnection of S. ❑ Repair of an <br /> ____System ______f_`-System _____________ Tank Only_ ____________ ExistingSystem _________Exlstlnc�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❑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 15. Perc. Rate 6. System Elev. 7. Fina[ Grade <br /> �O Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) p Elevation <br /> ti� l�0 Feet s-s Feet <br /> VII. TANK Cal pacit <br /> r. <br /> y site <br /> INFORMATION in gallons G otons auks Manufacturer's Name ConcrePrefate Con- Steel glass Plastic App- <br /> New Existin strutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank Soo ❑ ❑ 1 ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber Li ❑ n ❑l 1 11 <br /> Vlll. 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:(N St a s) MP/MPRSW No.: Business Phone Number: <br /> c OP 22S$St <br /> P mber's Address(S,reet,City State,Zip Code): ! <br /> (oD i4,,Jy 35 L��85`Tfr4 <br /> IX. COUNTY/DEPART ENT USE ONLY <br /> ❑Disapproved Sanitary Perm1}t Fee (includes Groundwater at7ssuelssuing Agent S nature(No a sroved YDhargeFee)v pp ❑Owner Given Initial /� g <br /> Adverse Determination O13✓ <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.11/97) DISTRIBUTION: Original to County,One copy To: Safety,8 Buildings Division,Owner,Plumber <br />