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Saf y and Buildings Division <br /> visconsiSANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> n In accord with ILHR 83.05,Wis.Adm.Code P 0 Box 7302 <br /> Department of Commerce Madison,WI 53707-7302 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County <br /> than 8 tie x 11 inches in size. �--;� <br /> • See reverse side for instructions for completing this application StdreSanitaryPermit N b r <br /> Personal information you provide may be used for secondary purposes ❑Check it revision to previous application <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATI N I ^`f <br /> Property Owner Name Property Location <br /> 1/4 1/4,S ,2(. T44 ,N,R I5 E(okw) <br /> PropertOwner's Maifin Address Lot Num er <br /> Ile)2.4 Veil W1 p � <br /> C y,State Zi Code Pone Number Subdivi ionName orCSM Number <br /> TYPE1, 1414 H. <br /> IL IN : (check one) ❑ State Owned ❑ I: Nearest Road <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms o <br /> vo�a9 OF Uat(SP41 <br /> 111. BUILDING USE: (If building type is public,checkallthatapply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo t)3zZI� <br /> 2 ❑ Assembly Hal[ 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 on line 6, if applicable) <br /> A) 1. New 2. ❑ Replacement 3. E] Replacementof 4. E3Reconnection of 5_ [:] Repair of an <br /> System System _______ __ Tank Only_____ ________ Existing System ---------E---is--------- <br /> B) <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 /> 1AlSeepage <br /> Seepage Bed 21 C]Mound30 Specify Type 41 ❑Holding Tank <br /> 1 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.Area4. Loading Rate 5.Perc. Rate 6. System Elev. 7. Final Grade <br /> Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Q / Elevation <br /> Q-06 f�—� 1 •`�' Feet 3. Feet <br /> Ca acct <br /> VII. TANK in gallons Tota[ #OfPrefab. Site Fiber- Plastic Exper. <br /> INFORMATION New Existin Gallons Tanks Manufacturer's Name Concrete st uocnted steel glass App. <br /> Tank Tanks MTT <br /> Septic Tank or Holding Tank U�/r-/ ❑ ❑ ❑ ❑ ❑ <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 /> Plumber's Name:(Print) Plu er's ignature:(N St a ) MP/MPRSW No.0 Bu iness Phone Number: <br /> I �J Q <br /> L + <br /> PI mber's Address(Stre ,City, tate,Zip Code): Vjuei JUL. <br /> IX. COUNTY/DEPAftrMVNT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (includes Surcharge <br /> water ate slue Issuing A Sig a re ps) <br /> roved OTr� Surcharge Fee) <br /> pp ❑Owner Given Initial <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.11197) - DISTRIBUTION: Original to County,One copy To: Safety&Buildings Division,Owner,Plumber <br />