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AS <br /> Safety and Buildings Division <br /> �consin SANITARY PERMIT APPLICATION 201 E.Washington Ave. <br /> In accord with ILHR 83.05,Wis.Adm.Code P.O.Box 7969 <br /> Department of Commerce Madison,WI 53707-7969 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County 2� <br /> than 8112 x 11 inches in size. &tA/1/E-1-F_ J <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> The information you provide ma be used b other government agency programs �� ` tb <br /> Y P Y Y 9 9 Y P 9 ❑Ch II revision vious application ju <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Numbers , <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION f <br /> Property Owner Name LSubdivision <br /> roperty Location <br /> It/_,Q I N 1/4 LJ 1/4,S p T �jg ,N, R ?(or)W <br /> Property Owners Mai Ing Address umber Block Number <br /> 5 r- r c c.1 (f/I 6L 12/f <br /> City,State �� J Zip Code Phone Number Name or CSM Number <br /> S CGL 'u1 i <br /> II. TYPE F BUILDING: (check one) ❑ State Owned y Nearest Road <br /> Public or 2 Family Dwelling-No.of bedrooms 3 ❑ fZVilage <br /> wn OF <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo <br /> 4 )6- <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. eplacement 3_ ❑ Replacement of 4. ❑ Reconnection of 5_ ❑ 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 UT eepage 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 /> Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> `f 2 (0 g 17v Feet .6✓Feet <br /> TANK Ca aclt <br /> VII. INFORMATION in gallons Total #of Manufacturer's Name Prefab. Con- Steel Site Fiber- plastic Exper <br /> New Existin Gallons Tanks Concrete strutted glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ <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 Signature:(No amps) w/MPRSW No.: Business Phone Number: <br /> Plumber's Address(Street,City,State,Zip Code): <br /> -3 L 6 7- 4g- Z_ L <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> 11 Disapproved Sanitar Permit Fee (Includes Groundwater ate IssuedIssuing Agent Signatu (N to s) <br /> �f r<harge Fee) <br /> roved ❑Ownes Determi al / 6 oZ <br /> Adverse Determination / <br /> X. CONDITIONS OF APPROVAL/REASONS FORDISAPPROVAL: <br /> SIRD-6"(R 1156) DISTRIBUTION: Original to county,One copy To: Safety&Buildings Division,Owner,Plumber <br />