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Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> AiscOnsin 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 n <br /> than 8vz x 11 inches in size. ,�j l-N � ocoZ�o� <br /> • See reverse side for instructions for completing this application State sanitary Permit Number <br /> ��© .3I0 <br /> Personal information you provide may be used for secondary purposes ❑Check if revision to previous application <br /> h'rivaty Law,s. 15.04(1)(m)]. State Plan I.D.Numb r <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION titL <br /> Property Owner Name Property Location C.� <br /> p d 1/4 1/4,S T / b /,N, R�6 E(or)W <br /> Proper#y O ner's Mailing Address G `� Al- Block Number <br /> P20 re3 <br /> Ci ,State Zip Code Phone Number Subdivision ameCann Numb r <br /> e r- W 5_t4,14 ( )27-3-2,9274 2C <br /> L1 <br /> 111. TYPE OF BUILDING: (check one) ❑ State Owned ityNearest Road <br /> ❑ Village 1/ <br /> El Public 1 or 2 FamilyDwelling-No.of bedrooms own OF d/� f1pi) O/Ji1)_S o <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo T1 3/ 07 Fo a <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 online B,if applicable) <br /> A) 1. ❑ New 2. ri Replacement 3_ ❑ Replacement of 4_ ❑ Reconnection of 5_ ❑ Repair of an <br /> ______System ___ _ ___---- __ __ Tank_Only______________ Existing System ________ Existing----- <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;ff4eepage Trench 22❑In-Ground Pressure ! 42❑Pit Privy <br /> 13❑Seepage Pit e , 43❑Vault Privy <br /> 14❑System-In-Fill <br /> Sia✓e cu..�.l c+® <br /> VI. ABSORPTION SYSTEM INFORMATION: <br /> 1.Gallons Per Day 2. Absorp.Area 13. Absorp.Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade <br /> Required(sq.ft.) I Proposed(sq.ft.) (Gals/day,/sq.ft.) (Min./inch) �,r/ Elevation <br /> SU p7�'6 <?57Fv /C I 'Feet 5f Feet <br /> Ca cit <br /> VII. TANK in gallons Total #of Prefab. Site Fiber-s Plastic EAxppepr. <br /> INFORMATIONGallons Tanks Manufacturers Name Concrete Con- Steel <br /> New Exist ons structed <br /> Tanks Tanks <br /> Septic Tank or Holding Tank ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber -5-019 ,5-0C) ❑ 11 1:1 ❑ F-1 <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) f / Plumber's Sig/nature: oStamps) MP/MPRSWNo.: Business Phone Number:_ <br /> Plumber's Address(Street,City,State Zip Code): <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Issuing A ent Signature( S ps) <br /> approved ❑Owner Given Initial /�� oeJ Surcharge Fee) ?-22-981�_ 1 <br /> VV Adverse Determination / /' 9 (/ <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.11/97) DISTRIBUTIONOriginal to County.One copy To: Safety&Buildings Division,Owner,Plumber <br />