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C <br /> SANITARY PERMIT APPLICATION t' and Buildings Division <br /> Visconsin <br /> 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 County ��D q/ <br /> than 8 1/2 x 11 inches in size. zc/y� `( <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> -5 3� <br /> Personal information you provide may be used for secondary purposes ❑Check if revision to previous app cation <br /> (Privacy Law,s. 15.04(1)(m)]. - State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATI N �� <br /> Pro erty Owner Name Property Location <br /> to �I/a E 1/4,S/a To ,N, R�6 E(or�V <br /> Verty 41.3Owner's Mailing�dc(r�� ./'1 of Number Block Number <br /> EEJJ�' <br /> el <br /> City,Stae 'F Zip Code /fl' Phone Number Subdivision Name or CSM Number <br /> �e yp 3 ( oe_ipI C/ �— <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned oIty Nearest Road// <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms 4;1o Town of eek o v T�--(� <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo 0!8 c�r,_3/;2 O a C9C.) <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. 1;;if-New 2. ❑ Replacement 3. ❑ Replacement of 4, ❑Reconnection of 5. ❑ Repair of an <br /> stem ____--__System _____________ Tank Only____---______- Existingstem ___---__ Existing <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 /> 12J.5eepage Trench 22❑In-Ground Pressure (1 42❑Pit Privy <br /> 13❑Seepage Pit 1'°-C' 43❑Vault Privy <br /> 14❑System-In-Fillti <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 /> Required(sq.ft.) P.rrooPosed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> d �-Q O >:o . S / Feet �'9 5--Feet <br /> TANK Cat <br /> VII. INFORMATION in gpalcflo s Total #Of Manufacturer's Name Prefab. Con Aper. <br /> Steel Fiber- Plastic <br /> New Existing Gallons Tanks concrete structed glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank SCJ Doo S�iSZGr� � ❑ ❑ ❑ ❑ ❑ <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:(PP nt) Plumber's Signature:(N tamps) I MP/MPRSW No.: Business Phone Number: <br /> Plumber's Address(street,city,State,Zip Code): <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> []Disapprove d- Sanitary Permit Fee BncludesGruundwater ate IssuedIssuing Agent Signat re(No a ) <br /> OVed r harge Fee) p <br /> I�Zppr <br /> ❑OwnerGiveninitial <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DI PPROVAL: <br /> SBD-6398(R.11/97) DISTRIBUTION: Original to County,One copy To: Safety&Buildings Division,Owner,Plumber <br />