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Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION 201 E.Washington Ave. <br /> V66nsin In accord with ILHR 83.05,Wis.Adm.Code P.O.Box 7969 <br /> Department of Commerce Madison,WI 53707-7 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County <br /> than 8 v2 x 11 inches in size. F)ur 1° <br /> • See reverse side for instructions for completing this application State Sanitary Peerrmit N/)umber <br /> The information you provide may be used by other government agency programs EICheck it revis'3nto previous a7icaci in <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION Alk <br /> Property Owner Name Property Location <br /> G SFJ14150 1/4,S 35 T -Nq ,N, R l'} .-W <br /> Property Owner's Mailing Ad ress Lot Number Block Number <br /> Ices C&_eoA%f%eW G11- I <br /> City,State Zip Code Phone Number Subdivision ame or CSM Number <br /> vi.o <br /> Sq Vol <br /> II. TWE OF BUILDING: (check one) ❑ State Owned ❑ it Nearest RoLdj <br /> ❑ village <br /> 171 Public Ol or 2 Family Dwelling-No.of bedrooms --,3— own Or K rji.F. Q L4-DLJ <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) may, 315 ae2 300 <br /> 1 E] Apartment/Condo 4"4_ T <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. VNew 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5, ❑ Repair of an <br /> System _ System Tank Only---------------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 /> 11 VrSeepage 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-Fil I <br /> VI. ABSORPTION SYSTEM INFORMATION: <br /> 1. Gallons Per Day 2. Abs orp.Area 3. Absorp.Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade <br /> Require (sq.ft.) Proposejj��(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> S� 6-A* I h'!of` 17 93./ Feet Feet <br /> TANK Capacity <br /> VII INFORMATION in gallons Total #of Manufacturer's Name Prefab. con Steel Fiber- Exper <br /> Gallons Tanks Concrete glass Plastic App <br /> New Existin structed <br /> Tanks T nks <br /> Septic TankoP4@Wieg-TafP 00 Oaf eat ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber 1 ❑ 1 ❑ ❑ ❑ ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersign%l,&sKme responsib4 ty for installs on of the onsite sewage system shown on the attached plans. <br /> Plumber'1 f!'�110% EXCAVATIO PI b natur (No Stamps) f#WMPRSW No.: Business Phone Number: <br /> N6228 Coun Line Rd, any <br /> Plumber's Addre E ip Code): <br /> MIT, OW <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Issuin yentS�inatuMStamps) <br /> �QApproved I ❑Owner Given Initial /�66t Surchargeree) `/{ <br /> Adverse Determination llr6� � 98 <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6388(R.11M) DISTRIBUTION: Original to County.One copy To: safety&Buildings Division,Owner,Plumber <br />