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G-r1 e.uvnyc� <br /> Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> sconsin 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 1 J <br /> than 8 1/2 x 11 inches in size. Rut-lle ( I a <br /> • See reverse side for instructions for completing this application State SanitaarryPeermit Number <br /> Personal information you provide may be used for secondary purposes ❑Cher"eviit sion t�� application <br /> (Privacy Law,s. 15.04(1)(m)). State Plan I.D.NyftJsA <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION VA— <br /> Property <br /> Property Owner NamProperty Location <br /> e <br /> D 1/4 1/4,S !6 T 4D ,N,R lb E(or) <br /> Property Owner's Mailing Ad ress Lot Number Blockumb r <br /> C_r%y,State I Zip Code Phone Number Subdivision Name or CSM Number <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ uty Nearest Road <br /> ❑ Village <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms 3 Town OF OAKUM! �FSM21196 D <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo 13ZS OB 5Q0 <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. q New 2. ❑ Replacement 3_ ❑ Replacement of 4_ ❑ Reconnection of 5. ❑ Repair of an <br /> -__Syrstem ........System ------------- Tank Only---------------Existing System----------Existlng.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 W 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 5.Perc. Rate 6. System Elev. 7. Final Grade <br /> Required(sq.ft.) 1Pro" <br /> p�sieod(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> 3 s 07 0 — 3.) Feet 7.Z Feet <br /> Ca acct <br /> VII. FORMATION in gallons Total #Of Prefab. Site Fiber- plastic Exper <br /> Gallons Tanks Manufacturer's Name Concrete Con- Steel glass App. <br /> New Existin structed <br /> Tanksl Tanks I <br /> Septic Tank or Holding Tank 10001 — W 10 ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ 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:( Stamps) MP/MPRSW No.: Business Phone Number: <br /> t( 476 s- G- 4I5 <br /> P mber's Address(Street,city State,Zip code): <br /> 't n _4WA W I - 54893 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (Includes Groundwater ate IssuedIssui entS na r tamps) <br /> AA roved Surcharge Fee) 5 <br /> pp ❑Owner Given Initial r�j <br /> Adverse Determination ...�t� <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.11197) DISTRIBUTION: Original to county,One copy To: Safety&Buildings Division,Owner,plumber <br />