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C-�v c <br /> : Safety and Buildings Division <br /> Vl <br /> In accord with ILHR 83.05,Wis-Adm.Code SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> sconsin P BMaa disoon,n,W1 53707-7302 <br /> Department of Commerce <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County <br /> than 81/2 x 11 inches in size. <br /> • See reverse side for instructions for completing this application S ate Sanitar P rr i111peerr <br /> Personal information you provide may be used for secondary purposes ❑Check I evisidn oo Pre 'OUs yion n, <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATI N YID, <br /> Property Owner Name Property Location <br /> 1/4 1/4,5 23 T gp ,N, R ((o E(orj�W <br /> Property Owner's Mailing Address Lot Nu er v Bleak-atrrtrb@t <br /> City,Stat p Zip Code Phone Number Subdivisionp orCSYNumber <br /> S ( ) 2- ��— <br /> . TYPEB D : (check one) ElStateVI <br /> State Owned Li �l Nearest Road <br /> I age <br /> Public 56 1 or 2 Family Dwelling-No.of bedrooms bil OF •$Cg0Od0V/E!R <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo = 4S 7_3 01 .5W <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 -----_-_Syrstem _____________ Tank Only_-____--______ Existing System .........Exlstln�Sl�stem <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[1 Specify Type 41 ❑Holding Tank <br /> 12 Seepage Trench 22 C]In-GroundPressure 42❑Pit Privy <br /> 13❑Seepage Pit 43❑Vault Privy <br /> 14❑System-In-Fill <br /> VI. ABSORPTION SYSTEM INFORMATION: X95- <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) 96.9 ElevationgS.g <br /> 30O _S00 $ Feet Feet <br /> VII. TANK Capacity Site <br /> in gallons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- plastic Exper <br /> INFORMATION New ExistingGallons Tanks concrete structed glass App <br /> - <br /> INFORMATION <br /> Tanks Tanks <br /> El El <br /> Septic Tank or Holding Tank 5D � a <br /> Lift Pump Tank/Siphon Chamber 1:1 13 1:1 11 <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) I Plumber's Signature:( Stamps) MP/MPRSW No.: Business Phone Number: <br /> )aww pr-N5, 191;04" 725851 (S'Yelo- Ri <br /> PI mber's Address(Street,City State,Zip Code). <br /> 2- ES Int - <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> E]Disapprove Sanitary Permit Fee (includes ate ssue Issuing a ign ure o mps) <br /> roved charge Fee) <br /> Vpp ❑Owner Given Initial /7 <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR D SAPPROVAL: <br /> SBD-6398(R.11197) DISTRIBUTION: Original to County.One copy To: Safety&Buildings Division,Owner,Plumber <br />