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Safety and Division <br /> *6�nsimn SANITARY PERMIT APPLICATION 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 <br /> than 8112 x 11 inches in size. <br /> • See reverse side for instructions for completing this application S ate SanitaryPeermiit/ttNumber /7L <br /> Personal information you provide may be used for secondary purposes ❑Check it reZ/to (�)eviou�I a,ion <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number / <br /> I. APPLICATION INFORMATION- PLEASE PRINT ALL INF RMATION <br /> Property Owner Name Property Location <br /> VELLOW LK. -� 1/4 1/4,5 2(:) T 40 ,N, R I E(or)© <br /> Prop Owner's Mailing Address Lot Number Bloc Number <br /> _O- x z —2 7- <br /> Cit ,State Zip Code Phone Number Subdivision Name CSM Num er <br /> OttJG Mtn- O Z clo121462-Ib7o CL. <br /> IL TYPE OF BUILDING: (check one) ❑ State Owned Oct' age Nearest Road <br /> Ej Public 1 or 2 FamilyDwelling ❑Vill-No.of bedrooms Town of 19KLA - RD. U <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) p <br /> 1 ❑ Apartment/Condo 175 ( VO <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. CK Replacement 3_ ❑ Replacement of 4. ❑ Reconnection of 5_ ❑ Repair of an <br /> System Tank OnlyExisting System..........ExistingSyrstem <br /> __ -__- __ _ ____--_ _____________ <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 M Seepage Bed 21 ❑Mound 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 S.Perc. Rate 6. System Elev. 7. Final Grade <br /> Re uired sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> 2-400 1 3+31Z ,7 /. Feet qS.'8 Feet <br /> VIICapacity <br /> TANK in gallons Total #Of Prefab. Site Fiber- Plastic Exper. <br /> INFORMATION New Existin Gallons Tanks Manufacturer s Name Concrete strutted Steel glass App. <br /> Tanks Tank <br /> Septic Tank or Holding Tank o ?j W/ Z W C-F ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber — 1600 1 SKAW ❑ ❑ ❑ ❑ ❑ <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:(N tamps) MP/MPRSW No.: Business Phone Number: <br /> I c N�4F,0 {-EoPlcrnl5 ,34z6 !S-S"- 4t57 <br /> P m ber's Address(Street,City,Stat ,Zip Code <br /> 2't (o O w S <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee t'"c'uaesGroundwater ate ssue Issuin A ntsig ature N amps) <br /> �-Ap roved Surcharge Fee) <br /> V� p ❑Owner Given Initial <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&Buildings Division,Owner.Plumber <br />