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0i) <br /> Safety <br /> Safety and Buildings Divislo�l <br /> �- SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> `VI sconsin 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 County /�v` � <br /> than 8 112 x 11 inches in size. V� <br /> • See reverse side for instructions for completing this application State Sanitary Permit Num be <br /> Personal information you provide may be used for secondary purposes ❑Checkvision to previous application <br /> [Privacy Law,s- 15.04(1)(m)]. <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Prope y Ow er Na / Property Location <br /> P Qd va va,S T ,N, R 3aff E(orAelk <br /> �N <br /> Propert O ner's Mailing Address Lo umber Block Number <br /> Z S v4 14 <br /> Cit ,State Zip Codeh Phone Number Subdivision Name or CSM Number <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ ityage Ne est Road <br /> Public 1 or 2 FamilyDwelling ❑ Vill-No.of bedrooms Town OF .el ar w d�G <br /> III. BUILDING USE: (If building type is public,checkallthatapply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo <br /> 00 <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. I1 New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> System System ___-- _ 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 /> 12 gj Seepage Trench 22❑In-Ground Pressure 42❑Pit Privy <br /> 13❑Seepage Pit 43❑Vault Privy <br /> 140System-In-Fill l ,' 1 re.76 <br /> VI. ABSORPTION SYSTEM INFORMATION: <br /> 1.Gallons P777 <br /> 2. Absorp.Area 3. Absorp.Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade <br /> ��f/� Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) TZ Elevation <br /> / 6 ;rte G_3 • 8 T�IM) 9t7zFeet 9-�6 Z.Feet <br /> Capacit VII. FORMATION Site <br /> in allons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- plastic Exper <br /> New Existin Gallons Tanks Concrete strutted glass App. <br /> Tanks Tanks t�T <br /> Septic Tank or Holding Tank �OOC� ( &0i`Cse r �y ❑ ❑ ❑ ❑ ❑ <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 /> Plu er'sName:(Pri Plu er'sSig Lure oSt mps) MP/MPR Business Phone Number: <br /> o 13, 6jS '!!S to��-zsaa <br /> PI bejAddress(Street,City.State,Zip Cgde): ear c ej <br /> . �✓ 7'Q <br /> IX. COUNTY/ DEPPAT7RTMENTJTUSE ONLY <br /> ❑Disapproved Sant ry Permit Fee (mdudesGroundwater ate s e Issuing ge Signat r mps) <br /> O-Approved ❑Owner Given Initial I 1 /5 Surcharge arge Fee) <br /> Adverse Determination f ' (/� <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.11/97) DISTRIBUTION: Original to county.One copy To: Safety&Buildings Division,Owner,Plumber <br />