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Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> `*Islconsin 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 count <br /> than 8 v2 x 11 inches in size. 4 <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> Personal information you provide may be used for secondary purposes ❑c i visio r`v ous application <br /> IPrivacy Law,s. 15.04(1)(m)). State Plan I.D.Number <br /> I. APPLICATION INFORMATION- PLEASE PRINT ALL INF RMATI N <br /> PropeR Owper Name O Property Location <br /> 6 e_ W 1/4 A)t-1/4,S of / T �6 N,R/,/, E(o W <br /> Property Owner3's Meiling Address Lot Number Block Number <br /> Cit,2State Zip Code Phone Number Subdivision Name or CSM Number <br /> II. TYPE OFIBUILDING: (check one) ❑ State Owned L] f-ity Nearest Road <br /> Public 1 or 2 FamilyDwelling ❑ V-No.of bedrooms 3 ownillage OF O �� :' 4�' `^ <br /> Number(s) <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Num <br /> /- <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 ❑ New 2. Replacement 3_ ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> S stem nystem ------------- Tank Only-___--___-__- Existing System --- ___ ExlstingSyfstem <br /> -------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 KSeepage 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 S. Perc. Rate 6. System Elev. 7. Final Grade <br /> Required(sq.ft.) Proposed(sq.ft.) (Gals/ ay/sq.ft.) (Min./inch) p Elevation <br /> e7 4 5/� a O .1�3 / ,I Feeti.. S Feet <br /> VII. TANK Capacity Site <br /> in gallons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- plastic App- <br /> New <br /> INFORMATION New Existin Gallons Tanks Concrete strutted glass Appp- <br /> . <br /> Tanks Tanks 1 <br /> Septic Tank or Holding Tank Q0� �0(] S A� 0' ❑ <br /> El 0 01 0 <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)D Plumber's Signature:(No amps) MP/MPRSWNo.: Business Phone Number: <br /> 9 <br /> / ��p-721yG� <br /> Plumber's Address(Street,City,State,ZP Code): <br /> IX. )COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sam}�ry Permit Fee (includes Groundwater7/77T�� <br /> ing A ent Signature(No Stamps) <br /> ❑ pp I` �� a Surcharge fee) <br /> proved ❑Owner Given Initial `'_�TTtDi <br /> Adverse Determination <br /> CD <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.11197) DIST818UTION: Original to County.One copy To: Safety&Buildings Division,Owner,Plumber <br />