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Safety and Buildings Division <br /> Visc' <br /> n51n SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> 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 <br /> than 8 112 x 11 inches in size. <br /> • See reverse side for instructions for completing this application State Sanitary NumberPe/rtNit <br /> Personal information you provide may be used for secondary purposes 0heck if re n to previCoas app IIcation <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number i <br /> I. APPLICATION INFORMATION- PLEASE PRINT ALL INF RMATI N <br /> PropertyOwner Name Property Location \ <br /> r T t' cv f}r iv e/45✓d 1/4,S 3 s_ T12B21ock, <br /> N, R /�E(or i <br /> Property 0 ner's Mailing Address Lot Number Number <br /> �- e �v — - <br /> Cit ,Sate Zip Code Phone Number Subdivision Name or CSM Number <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned U :ty Nearest Road n e <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms Cmt i Town of �r-�'°� /���e_ /-CA /1 r( <br /> III. BUILDING USE: (If buildingtype is public,check allthatapply) Parcel TaxNumber(s) <br /> 0 /Y — :3.33 s=- cD 7 c-) d <br /> 1 ❑ Apartment/Condo <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. E] Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5_ [:] Repair of an <br /> stem <br /> _Sy ________ <br /> stemSystem _____________ ______ank l y______________ Exi----y--- _________ExlstlnqSystem <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 CASeepage 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 Rate5.Perc. Rate 6. System Elev. 7. Final Grade <br /> Required(sq.ft.) Proposed(sq.ft.) (Gals/daylsq.ft.) (Min./inch) p Elevation <br /> 16-0 ���-j oda ,. / Y Feet � 9 Feet <br /> VII. TANK Capacity site <br /> in gallons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic App- <br /> - g <br /> INFORMATION New Existin Gallons Tanks Concrete strutted glass App.p- <br /> Tan'; Tanks <br /> Septic Tank or Holding Tank 1@0b 06c� A10 CW e__5 C_ o ❑ ❑ ❑ ❑ Er- ❑ <br /> Lift Pump Tank/Siphon Chamber EL ❑ ❑ 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 Sign ture:(No Stamps) MP/MPRSWNo.: Business Phone Number: <br /> Plumber's Address(Street,city,State,Zip Code): <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanit yPermit Fee includes Groundwater ratee Issuin A ntS atur ( tamps) <br /> rOVed Surcharge fee) <br /> 5Cpp <br /> Owner Given Initial <br /> 0 /1 Surcharge <br /> "�c <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.11/97) DISTRIBUTION: Original to county.One copy To: Safety&Buildings Division,Owner.Plumber <br />