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Safety <br /> ` %SCORS%D SANITARY PERMIT APPLICATION 201 W.Washmg,,,,,,,.,,,lue <br /> P O Box 7302 <br /> Department of Commerce In accord with Comm 83.05,Wis.Adm.Code Madison,WI 53707-7302 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County or �� <br /> than 8112 x 11 inches in size. � Yo (�1 <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number X� <br /> Personal information you provide may be used for secondary purposesC <br /> ❑ heck it r onTO( o <br /> application <br /> [Privacy Law,s. 15.04(1)(m)]. previous <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF ORMATI N <br /> Propert wner Name • Property Location <br /> O 1/4 1/4,S Z(e T 4j N, R 15' E(or OW <br /> Propert Ow er's pl ing Address Lot Number gf�klVpmber <br /> Citf,State I Zip Code FPhcne Number Subdivision Name or CSM Number <br /> i0 b ("ll5 > SISS <br /> TYPEBUILDING: (check one) ❑ State Owned_ ❑ City Nearest Road <br /> Public 1 or 2 Family Dwelling-No.of bedrooms Z- ❑ vilTown lageOF 5W ISS ^ <br /> Iy gggtv LIJ� <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) . <br /> 1 ❑ Apartment/Condo 032 $2..2(p 01 2,Ao <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,Et 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 /> 11RgSeepage Bed 21 E]Mound 30 C]Specify Type 41 ❑Holding Tank <br /> 1 ❑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.) Proposed(sq. ft.) (Gafs/day/sq.ft.) (Min./inch) n Elevation <br /> 300 Z r'� 93•r Feet �S 6 Feet <br /> VII. TANK Capacity <br /> INFORMATION in gallons Total #of Manufacturer's Name Prefab. Site Fiber- Exper <br /> New Existin Gallons Tanks Concrete Con- Steel glass Plastic App <br /> Tank Tanks <br /> structed <br /> Septic Tank or Holding Tank El 1:1 1 1:1 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:(N tamps) MP/MPRSW No.: Business Phone Number: <br /> R0 S �I-4 22S�g5( -115- ,- IS7 <br /> Plu ber'sAddress(Street, ity,state Zip Code): <br /> ;2_77(60t4 AS LJr. . 1-893 <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> rcl <br /> Disapproved itar PermitFee (includes Groundwater ate ssue Issuing Agent gnat a(No ps) <br /> roved ��+ urchargefee)PP Owner Given Initial !J- <br /> Adverse Determination ` <br /> 601 <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.4/99) DISTRIBUTION: Original to County.One copy To: Safety&Buildings Division,Owner,Plumber <br />