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Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> P O Box 7302 <br /> NVis'consin In accord with ILHR 83.05,Wis.Adm.Code Madison,WI 53707-7302 <br /> Department of Commerce <br /> • Attach complete plans(to the county copy only)for the system,on paper not less Cou ty li& D <D <br /> than 81/2 x 11 inches in size. <br /> • See reverse side for instructions for completing this application stawsanitary PermiEN �rPersonal information you provide may be used for secondary purposes ❑Check it revision to pplication y j <br /> (Privacy Law,s. 15.04(1)(m)]. State Plan LD Ny�er"r J <br /> 1. APPLICATION INFORMATION- PLEASE PRINT ALL INF RMATION 8 (/O"JL <br /> PropecWowner Name Property Location <br /> IG 1/4 1/4,5 35' T ,N, R (� E(or W <br /> Property wner's Mailing Address Lot Numbrr <br /> C'ty,State Zip_! <br /> -.ode od — P ne NumberSubdivisi n Name or CSM Number <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned 0 Lity t Nearest Road <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms �-- W Town of N W <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> Q/g _ -3 -35-- D4 ROO <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) 1.0M New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> __System __ _System---__ _ __ TankOnlY ___ _ _ _ Existing System ________ ExtsttngSystem <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 2 ) Mound 30 C]Specify Type 41 ❑Holding Tank <br /> 12 E]Seepage Trench 2 2;)6 <br /> ❑❑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) _ levation <br /> 50 ZSZ f, z 6• S Feet $- do Feet <br /> Ca aclt <br /> VII. TANK in gallons Total #of Manufacturers Name Prefab. Con Steel Fiber- Plastic Aper. <br /> INFORMATION New Existin Gallons Tanks concrete strutted glass App- <br /> Tanks Tan ks <br /> Septic Tank or Holding Tank ❑ <br /> 11 <br /> Lift Pump Tank/Siphon Chamber 1:1 E] ❑ <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 Vgnature:( St s) MP/MPRSW No.: Business Phone Number: <br /> - S <br /> PI mber's Address(Street,Cit , tate,Zip Code): ` <br /> IX. COUNTY/DEPA T NT USE ONLY �l <br /> []Disapproved Sanitary Permit Fee (Includes Groundwater ate ssue Issuing g tSi tur oS ps) <br /> VP <br /> []Owner Given Initial O <br /> SU - / <br /> Adverse Determination / Q <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.11/97) DISTRIBUTION: Original to County.One copy To: Safety 8 Buildings Division,Owner,Plumber <br />