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Safety and Buildings Dlvislon yL <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> Wisconsin 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 81/2 x 11 inches in size. S 1 � c0 <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> Personal information you provide may be used for seconds �i�� <br /> y p y secondary purposes ❑Check i revi ion 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 a a a <br /> Property Owner N me Property Lo tion C� n d <br /> `� _�,S a9 T N, R /8A(or W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 1/0 / -3 el— S <br /> City, tate ' Zip Code Phone Number Subdivision Name or CSM umbe O <br /> o 76 <br /> 11. P F B ILDI : (check one) ❑ State Owned ❑ it� Nearest Road <br /> C <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms Tc❑ Vilage of r <br /> J / <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax NuLmber(s) l <br /> 1 E] Apartment/Condo J2 // — /�%� b <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. New 2. [:] Replacement 3. E] Replacementof 4. E] Reconnection of 5_ E] Repair of an <br /> N__Syrstem 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 /> 12 E]Seepage Trench 22❑In-Ground Pressure 42 E]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. 7. Final Grade <br /> J Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ftJ (Min./inch) Elevation <br /> 1(S0 �— Feet Feet <br /> Ca acct <br /> VII Site <br /> FORMATION in gallons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- plastic Exper. <br /> New Exist ng Gallons Tanks Concrete strutted glass App. <br /> Tanks Tanks pt <br /> Septic Tank or Holding Tank p�e[Q �(�� Z ❑ ❑ ❑ 1 ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ 1 ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumbe 's Na e:(Print) Plumbe ' Ignatu (No -- P PRSW No.: Business Phone Number: <br /> u rU 3a��s� 71 9 . 169 fs <br /> Plumber's Address(Street,City State Code): 4_ <br /> D - G�-t - <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (Includes Groundwater [ate IssuedIss*Anti e oStamps) <br /> =CONDITIONS <br /> ❑ Surcharge Fee) <br /> Owner Given Initial / 7� � _ <br /> Adverse Determination <br /> OF APPROVAL/REASONS FOR DISAP ROYAL: <br /> SBD-6398(R.11/97) DISTRIBUTION: Original to County,One copy To: Safety a Buildings Division,Owner,plumber <br />