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Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> Visconslfn In accord with ILHR 83.05,Wis.Adm.Code P O Box 7302 <br /> Department of Commerce Madison,WI 537 7-7302 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County <br /> than 8 112 x 11 inches in size. IT, u r�a rj <br /> • See reverse side for instructions for completing this application St to Sanitary Permit-Number[,/�/ ���� `` <br /> Personal information you provide may be used for secondary purposes ❑Chmit it revision:3 us application X J <br /> e <br /> (Privacy Law,s. 15.04(1)(m)]. <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION <br /> Prop y Owner Name Property Location - <br /> 1/4 1/4,5 32 T ,N,R�� E(or <br /> Property Owner's Mailing Address Lot Number Block umber <br /> 2A(o W I . ST, A 302 <br /> Cit ,State Zi Code Phone Number Subdivision Name or CSM Number <br /> u 1( IS )3SI-O l SEFFSR) S <br /> II. TYPL Of i : (check one) ❑ State Owned ❑ ItyyI N rest Road <br /> Public 1 or 2 FamilyDwellin -No.of bedrooms 2— Vowan OF K04,40' IWA 41ti4TO&I <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo OzD qZZ57 01 7042 <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. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> System System _ Tank Only Existing System----------ExistingSystem <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 /> 11eepage Bed 21 []Mound 30❑Specify Type 41 C]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. 7. Final Grade <br /> 30o Requ'red(sq.ft.) Proposed.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> -1-I Feet .3j Feet <br /> CANKa aclt e <br /> VII N ORMATION in allo s Total #of Prefab. Site Fiber- Exper. <br /> g Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App <br /> New Existingstructed <br /> _750 Tanks Tank <br /> Septic Tank or Holding Tank �. ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ I ❑ I ❑ ❑ <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: o amps) MP/MPRSW No.7 Business Phone Number: <br /> I c AAKD o 22$$SI S- - 41$ <br /> P mber's Address(Street,Ci State,Zip Code): <br /> w Wi . -54123 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved 5a tary Permit Fee (IndudesGroundwater ate ssue Issuing Agent Sin ure(No Sta s) <br /> roved halge Fee) <br /> pp ❑Owner Given Initial <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FORDISAPPROVAL: <br /> SBD-6398 IRA 1/97) DISTRIBUTION: Original to County,One copy To: Safety&Buildings Division,Owner,Plumber <br />