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Safety and Buildings <br /> Visconsin SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> P O Box 7302 <br /> Department of Commerce In accord with Comm 83.05,Wis.Adm.Code Madison,WI 53707-7302 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less Coy a a-�a <br /> than 8 1/2 x 11 inches in size. QJ <br /> • See reverse side for instructions for completing this application StlTe Sanitary Perm1t Numbeeerr Q� <br /> Personal information you provide may be used for secondary purposes [I Check it revisio Zvls appl rion r <br /> (Privacy Law,s. 15.04(1)(m)J. State Plan I.D.Number n' <br /> I. APPLICATION INFORMATION- PLEASE PRINT ALL INF RMATION I <br /> Propert O ner N me Property Location <br /> 1/4 1/4,S IZ T qD ,N, R r5 E(or) <br /> Property9wner^Mailing Address Lot Numbbrr Block Number <br /> sw— <br /> City,State Lam ZipSub Code Phone Number ivisioon Name or CSM Number <br /> of rl MN 55343 Liz <br /> )q%*_' 90 ut2E A o V•�> <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ City Nearest Road <br /> village <br /> Public or 2 FamilyDwelling-No.of bedrooms Z own OFAcM&j [jk6ftM9iE <br /> III. BUILDING USE: (if building type is public,check all that apply, Par cel TaxNumber(s) <br /> 1 ❑ Apartment/Condo I O/Z 97Zr D4 4b)` <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 online B,if applicable) <br /> A) 1. ❑ New �►teplacement 3. E] Replacementof 4. E] Reconnection of 5. E] Repair of an <br /> ___System -________ystem -__- __ Tank Only___----___ __ Existing System __-___ ExistingSystem <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 ❑Holding Tank <br /> 1 eepage 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 /> Requir�(sq.ft.) Pro osed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) e Z .3 Elevation <br /> _50O S , r� _t Feet Wtj Feet <br /> Ca act <br /> VII. TANK in allons Total #of Prefab. Site Fiber- Exper <br /> INFORMATION g Gallons Tanks Manufacturers Name Concrete Con Steel glass Plastic App <br /> New Existin structed <br /> Tank Ta,,nnkks <br /> Septic Tank or Holding Tank � a� S� Ej ❑ ❑ ❑ El <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 Signa re:(N amps) MP/MPRS,(WW N[�o�.:] Business Phone/Number:: <br /> LI-plmb <br /> �7VJ1 r�— by 'J <br /> PI mb`err's Address Street,Cit ,State,Zip Code): <br /> IX. COUNTY/ DEPART NT USE ONLY <br /> ❑Disapproved tary Permi a (Includes Surcharge <br /> water ate ssue Issuing Ag n ign ure(N t ps) <br /> Surcharge Pee) A <br /> proved E]Owner Given Initial 7/af(���� <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.4/99) DISTRIBUTION: Original to county.One copy To: Safety 8 Buildings Division,Owner,Plumber <br />