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Saf <br /> and <br /> ' SANITARY PERMIT APPLICATION 201 E.Washington Division <br /> *6onsin 201 E.Washington Ave. <br /> In accord with ILHR 83 05,Wis.Adm Code Box <br /> Department of Commerce Mad Madison,WI WI 53707-7969 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less 2 County �L <br /> than 8 1x 1 1 inches in size. 2 1 <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> The information you provide may be used by other government agency programs <br /> (Privacy law,s. 1 5.04(1)(m)]. Elk <br /> Checvislon to previous application <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INE OR ATION I <br /> Property Owner Na e r Property Location /� <br /> r G e /L-2 <br /> 1/4S� 1/4,Sa � T ,N, R E(or <br /> Property Owner's Mailing Address Lot Number Block Number <br /> City,Stat Zip ode Phone Number Subdivision Name or CSM Number <br /> II. YPE 1 D NG: (check one) ❑ State Owned It Nearest Roadr„� 7_ <br /> Public 1 or 2 FamilywellingD - No.of bedrooms C town OF 0, <br /> Co. 'r� <br /> Ili. BUILDING USE: (If building type is public,check all that apply)E] AWN <br /> umber(s) n L� �t j� <br /> 1 Apartment/Condo 0 a0_ 130 �S 3 — �ve-') <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_ C4 New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ 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 6ySeepage 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 /> 1- <br /> J/ <br /> Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) 75-- 71 <br /> Elevation <br /> 5_ 7,56 / �' 7 Feet Feet <br /> Capaat <br /> VII. INFORMATION in allons Total #of Manufacturer's Name Prefab. Site Con- Steel Fiber- Exper. <br /> nf <br /> Gallons Tanks Concrete glass Plastic App <br /> New Existin structed <br /> Tanksl Tanks <br /> Septic Tank or Holding Tank QQC1 El ❑ ❑ 11 El <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:(Print / Plumber's Signature:(No Stamps) / MP/MPRSWNo.: Business Phone Number: <br /> Plumber's Ac dress(Street,City,State,Zip Code): <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (Includes Groundwater atessue Issu g A en ature(No Stamps) <br /> Approved ❑Owner Given Initial $ �7 TSurcharge Fee) <br /> Adverse Determination / /V 'Dz) �~ <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBC14M(R.11/96) DISTF BUTION: Original to County,One copy To:Safety 8 Buildings Division,Owner,Plumber <br />