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VLvonsin <br /> SANITARY PERMIT APPLICATION 201 W.WahingtonAveulen <br /> Department of Commerce In accord with ILHR 83-05,Wis.Adm.Code P 0 BOX 7302 <br /> Madison,WI 53707-7302 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less Coun <br /> than 8 1/2 x 11 inches in size. <br /> • See reverse side for instructions for completing this application State <br /> Sanitary Permit Number <br /> Personal information you provide may be used for secondary purposes �530 339 <br /> (Privacy Law,s. 15.04(1)(m)]. ❑Check if revision to previous application <br /> state Plan 1.U.NI. APPLICATION INFORMATION- PLEASE PRINT ALL RMATI N % 5_0 <br /> 6S_ <br /> Prope yOwerName Property Locationd e <br /> 1/4 1/4,S- T N, 11,4� E(o <br /> Property Owner's Mailing Address L <br /> 02 " ��,_-;e Block Number <br /> Cit ,State 1 Zip Code Phone Number Subdivision Name or CSM Number <br /> e ��! , j 0 ( ) <br /> II. TY LDING: (check one) ❑ State Owned ❑ It Nearest Road <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms 0 Niage /4�N <br /> Town OF"" <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax ber(s) <br /> 1 ❑ Apartment/Condo � 0`j�3S d �C�q <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Re airs El Outdoor Recreational Facility <br /> 4 p 11 ❑ Restaurant/Bar/Dining <br /> ❑ Church/School School 8 ❑ Mobile Home Park <br /> 5 ❑ Hotel/Motel 12 ❑ Service Station/Car Wash <br /> 9 ❑ Office/Factory 13 E] 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.,g}Beplacement 3_ ❑ Replacement of 4_ Q Reconnection of 5. Repair of an <br /> S stem -- -------Tank---y------------ ExistingS stem _ Existing System <br /> �--------------ystem-- Tank Only ------- Y--- ❑--p--�-y---- <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 �IHoldi ng Tank <br /> 12❑Seepage Trench 22❑In-Ground Pressure 42❑Pit Privy <br /> 13❑Seepage Pit <br /> 14 43 El Vault Privy <br /> E]System-In-Fill <br /> VI. ABSORPTION SYSTEM INFORMATION: <br /> 1. Gallons Per Day7]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) Elevation <br /> VII. TANK Capacity <br /> Feet Feet <br /> INFORMATION in gallons Total #of Prefab. Site Fiber- Exper <br /> New Existin Gallons Tanks Manufacturer's Name Concrete Con- Steel lass Plastic xp <br /> Tanks T nks structed g pp <br /> Septic Tank or Holding Tank 4 <br /> f ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber El ❑ ❑ ❑ ❑ ❑ <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 Na e:(Pri ) Plumber'sSignature:(N Stamps) MP/MPRSW o.: Business Phone Number: <br /> Plumber's Address(Street,city,State,Zip Code): <br /> IN. COUNTY/DEPARTMENT USE ONLY <br /> E]Disapproved SanitaryPermit Fee (Includes Groundwater a e Issued <br /> *Approved] Surcharge fee) Issuing Agent Signature NoStamps) <br /> ❑Owner Given Initial , �� /I / f� / <br /> Adverse Determination Al7' ISD, <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(8.11/97) DISTRIBUTION: Original to County,one copy To: Safety&Buildings Division,Owner,Plumber <br />