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Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> ions►n n accord Id with ILHR 83 05,Wis.Adm_Code P O Box 7302 <br /> ant of Commerce Madison,WI 53707-7302 <br /> • ach complete plans(to the county copy only)for the system,on paper not less County <br /> than 8112 x 11 inches in size. SO a tT15 <br /> • See reverse side for instructions for completing this application State Sanitary <br /> �)Permit <br /> /Number <br /> Personal information you provide may be used for secondary purposes E]Chet ITTrev., to prevl`o(s application <br /> [Privacy Law,s. 15.04(1)(m)]. C <br /> State Plan I.D.Number Q <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION if Ilo <br /> Pro y O ner Na e / Pro V) <br /> t r � � d S' �;�rr ��Ira,S /Y T 3� ,N, R l,57E(or)W <br /> Property Owner's Mailin th ress L /t� Lot Number Block Number <br /> �J <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> rlec Ilea, C_ 6.e-/, �7 ('7/s) <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ CityNear t Road <br /> Public 1 or 2 FamilyDwelling- No.of bedrooms ❑ Town of 241le Z,4 41e pc� <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <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 /> ___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 ❑Seepage Bed 21 []Mound 30❑Specify Type 41 ❑Holding Tank <br /> 12 0 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 /> d Required(5q. ft.) Propgseq.�ft.) (Gals/day q.ft.) (Min./inch) � Elevation <br /> �� <br /> -3 //�� r 9//r /76Feet ?:5�r 9S Feet <br /> Capact <br /> VII INFORMATION in allons Total #of Manufacturer's Name Prefab Site Con- steel Fiber- Exper <br /> Gallons Tanks Concrete glass Plastic App <br /> New Existin strutted <br /> Tanks Tanks / ` <br /> Septic Tank or Holding Tank �'jo (.(J.�C' ❑ ❑ ❑ ❑ ❑ <br /> LIR Pump Tank/Siphon Chamber L ❑ ❑ ❑ ❑ ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plu�r's Name: Print)e7 Plum Signat ( amp MP/MPRSW No.: <br /> .Business Phone Number: <br /> Plumber's Address(Street,Cit ,State,ZipC cle): r <br /> I OUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee includes Groundwater ate IssuedIssuing Ag tSignature(NoStamps) <br /> A I pproved ❑ surcharge Fee) �j' <br /> Owner Given Initial J�Sr b� 11S ,., mCU�YI� <br /> Adverse Determination .�4.�'�-�L <br /> X. CIONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.11197) DISTRIBUTION: Original to County.One copy To: Safety&Buildings Division,Owner,Plumber <br />