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Safety and Buildings Division <br /> VisconsiSANITARY PERMIT APPLICATION 201 E.Washington Ave. <br /> n In accord with ILHR 83.05,Wis.Adm.Code P.O.Box 7969 <br /> pepartment of Commerce Madison,WI 53707-7969 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County �f l <br /> than 81/2 x 11 inches in size. O k Alf TT 0-� <br /> • See reverse side for instructions for completing this application State sanitary Per it Number C <br /> The information you provide may be used by other government agency programs ❑Check if re .Yt revlous ap kation <br /> [Privacy Law,s. 15.04(1)(m)1. <br /> State Plan I.D.Numbr <br /> 1. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION <br /> Property Owner Name Property Location <br /> �bO!.) 3-rR A/� S (�/4 Sts-,/a,S 2,37- T 3Q r N. R /4 )W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 2/o W, 5-th sr. 80, S /007 1 <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> E MAI 6'S934 (6v7) -30 <br /> 11. TYPE F BUILDING: (check one) ❑ State Owned ity Nearest Road I/ * <br /> ❑ Village RUS t�PPGe- <br /> Public 1 or 2 Famil Dwelling-No.of bedrooms .3 Town OF <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> oz4 -3/25-- o1- 700 <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. pg New 2. ❑ Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5. E] 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 ❑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 /> C—r� Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./in h) �+► , Elevation <br /> y '1 v 5 6 '7-2 09 � . 'Keet JOO Feet <br /> TANK Capacft Site <br /> VII. INFORMATION in allons Total #of Manufacturer's Name Prefab. Con- steel Fiber- Plastic Exper <br /> New Existin Gallons Tanks Concrete strutted glass App. <br /> Tanks Tanks [� <br /> Septic Tank or Holding Tank /7 /�I? 1 t V�b Se a ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber I ❑ ❑ ❑ ❑ ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation f the onsite sewage system shown on the attached plans. <br /> Plumber's Name:(Print) j� Plum r' ignatur tamps) MP/MPRSW No.: usine Phone Number: <br /> o�w Solo�r� <br /> 22 3 771 7rs 376- 2��r� <br /> Plumber's Ar dress(Street,City,State,Zip Code): <br /> c�_ 41 ^Guv "I t 4y ? <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (includes Groundwater ate I <br /> ssued Issuing Age t Sign re No&a ,) <br /> hproved ❑Owner Given initial f7nargefee) <br /> Adverse Determination ( J <br /> X. CONDITIONS OF APPROVAL/REASONS FORD APPROVAL: <br /> A(N rtM) DISTRIBUTION: Original to County.One copy To: Safety&Buildings Division,Owner,Plumber <br />