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Safety and Buildings Division <br /> *19consin SANITARY PERMIT APPLICATION P O W.Box shington Avenue <br /> 02 <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 Count <br /> than 8 1/2 x 11 inches in size. rn,P <br /> • See reverse side for instructions for completing this application State SanitaryPermit Number 7v� <br /> Personal information you provide may be used for secondary purposes ❑check it revisioniO i6useplication <br /> (Privacy Law,s. 15.04(1)(m)1. <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATI N <br /> Propyrty wner_N me (I Property Location <br /> l�ee t4-e P, k1Gt/I/av4,S l 7 T 4/O ,N,R IS W <br /> Propert Owner's Mailing Address � L Lot Number Block Number <br /> F3- —( u <br /> CitState Zip Code Phone Number Subdivision Name or CSM Number <br /> Q K WI <br /> Sqa 171Y)3�6'W26 <br /> II. TYPE OFIFUTMI : (check one) ❑ State Owned ❑ City Nearest Road D <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms 3 m Towan of GL Seri Couti �� <br /> III. BUILDINGUSE: (if bu I Id I ng type is pu blic,check a I I that a poly) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo 00- 4f,_,�17 b /Ott <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 Existing System <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 D9 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.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> 4/s 3 C� • �S.C7 Feet q ,© Feet <br /> Ca act <br /> VII FORMATION ing gallons Total #of Manufacturer's Name Prefab. Site Con- steel Fiber- Exper <br /> Gallons Tanks Concrete glass Plastic App <br /> New Existin structed <br /> Tanks Tanks <br /> Septic Ta or Holding TankI }� ❑ ❑ ❑ ❑ ElLift Pump Tank/Siphon Chamber ❑ ❑ ❑ I ❑ ❑ I ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsib'lity for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Nae:(Print) PI ber's Signat e: o Stamps) MP/MPRSW No.: Business Phone Number: <br /> Nets aer r <br /> Plumber's Address(Street,City,State,Zip d ): r <br /> q s- C.o r- � b Lj4ebS`-Ler_ 5 x(2213 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sa iry Permit Fee (Includes Groundwater Dat IssuedIssuingD*RAge Signat a(NO S) <br /> proved ❑ Sur arge fee) /J <br /> Owner Given Initial ���--���fff / � <br /> Adverse Determination / <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL- <br /> 1�k Kt, A%� <br /> SBD-6398(R.4/99) DISTRIBUTION: Original to County,One copy To: Safety&Buildings Division,Owner,Plumper <br />