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—/2,in <br /> Safety and <br /> Buildrings Division <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> Visconsin 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 County <br /> than 8 1/2 x 11 inches in size. <br /> • See reverse side for instructions for completing this application State Sanitary Permit <br /> itNumber <br /> Personal information you provide may be used for secondary purposes E]Check if rii pr&vious application <br /> [Privacy Law,s. 15.04(1)(m)]. y`J <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATIONUj <br /> Prop y O er N e Property Location <br /> l 7/4 IV6FI/4,S /,2, T 3Q ,N, R/5' F�440 W <br /> Prope writer's aJrhQ Address Lot Number Block Number <br /> ClStaZip de P ne Number Subdivision Name or CSM Number v z <br /> — <br /> 11. TYPE OF B ILDING: (check one) ❑ State Owned City Nearest Road <br /> E) Village j�' / {/ y✓ <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms Town of / O <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 E] Apartment/Condo C,57tIq —,�2;2,/ Z _e / — q-0e) <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. rp/flew 2. E] Replacement 3. E] Replacement of 4. E] Reconnection of 5. ❑ Repair of an <br /> __System System _ 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❑Specify Type 41 ❑Holding Tank <br /> 12Seepage Trench 22[:]In-Ground Pressure 42 E]Pit Privy <br /> 13 Seepage Pit ® �t 43❑Vault Privy <br /> 14❑System-In-Fill JXI CIZ7r 151V 5 fALC'��L c7 � 1yt <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. 17. Fina[ Grade <br /> 150 Required (sq.ft.) Proposed(sq. ft.) (Gals/da sq.ft.) (Min./inch) Elevation <br /> / Q Feet `11 Feet <br /> TANKCa acct <br /> VII Site <br /> INFORMATION in gallons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Exper. <br /> Gallons Tanks Concrete lass Plastic A <br /> New Existin structed 9 pp <br /> Tanks Tanks <br /> eptic Tan or Holding Tank <br /> __fX <br /> Lift Pump Tank/Siphon Chamber ❑ Q ❑ Q ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plu er's Name:(Print) / PlumbSi ature: No mp t IMP/MPRSV1NO.: Business Phone Number: <br /> �7 / � � ef <br /> Plu isA1-2e,(Street,City,StaSe,.2ip Code): �� <br /> IX. COUNTY/✓✓✓✓ {{DD--EPART7/MME INT USE ONLY /l(� <br /> ❑Disapproved Sanitary Permit Fee (includes Groundwater r;le;l;ssued, Issuing Ag tSignature o mps) <br /> roved urcharge Fee)pp ❑Owner Given Initial J �etermination ' <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.11/97) DISTRIBUTION: Original to County.One copy To: Safety&Buildings Division,Owner,plumber <br />