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SANITARY PERMIT APPLICATION Safety and Buildings Division <br /> Visconsin 201 W.Washington Avenue <br /> In accord with ILHR 83.05,Wis.Adm.Code P O 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 Countya <br /> than 8 1/2 x 11 inches in size. <br /> • See reverse side for instructions for completing this application Sta a Sanitary Permit Number <br /> 6 0- <br /> Personal information you provide may be used for secondary purposes ❑Check it revisio�p�ioapplication <br /> IPrivacy Law,s. 15.04(1)(m)]. State Plan.I.D.Numb r <br /> r <br /> I. APPLICATION INFORMATION - PLEASE PRINTALL INE RMATION oq �5 <br /> Propew`�Owner Nam Property Location <br /> NORM V IA -r -y„i1/4 w 1/4,S ( I T 3Cj ,N,R tQ E(orc' <br /> Property Owner's Mailing Address Lot Number @mer <br /> 555 SWARD SF- I 2 - 10 AuZC PAPWLS <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> III. TYPE 0a t MN . I� ((�s() T- -(�31a <br /> F BUILDING: (check one) ❑ State Owned 0 C-Ity Nearest Road <br /> Z ❑ Village - <br /> y <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms Town OF`r IAC1fZ$(�LArr� SQ�t 1 R� <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo X40 Coll C) O,` <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Out or Recr ational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Resta 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. 14Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> System _ System ------------- Tank Only---------------ExistinQSystem ________ 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 211ZMound 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 5. Perc. Rate 6. System Elev. 1 7. Final Grade <br /> Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> 300 2$0 329 0 11 j()I .A&5 Feet 103-1!> Feet <br /> Ca acit <br /> VII in gallons Total #of Prefab. Site Fiber- Plastic Exper. <br /> INFORMATION <br /> Gallons Tanks Manufacturer's Name Concrete Con- Steel glass App. <br /> New Existin structed <br /> Tnnkss Tanks <br /> -1 <br /> Septic Tank or Holding Tank -7—So ❑ ❑ ❑ ❑ ❑ <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) Plumber's Signature: No mps) <br /> [MP/1MPRSW No.: Business Phone Number: <br /> 1c14AIZo <br /> P umber's Address(Street,City,State,Zip Code): <br /> 2_1-716c,0 A w -�35 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ,,,���yy/�I��� ❑Disapproved Sanitary Permit Fee (Includes Groundwater ate IssuedIssuing Agent Si nature(No S am s) <br /> IgA roved D Surcharge Fee) <br /> pp ❑Owner Given Initial O- j/7 <br /> Adverse Determination <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 />