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Safety and Buildings Division <br /> ` lsbo sin SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> In accord with ILHR 83-05,Wis.Adm.Code P O Box 7302 <br /> Department of Commerce Madison,WI 53 07-7302 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less Count <br /> than 8 t/z x 11 inches in size. u y © S57 <br /> • See reverse side for instructions for completing this application State Sanitary PPeelrmit N <br /> [Privacy Law,s. 15.04(1)(m)). E]information you provide may be used for secondary purposes E]cnec revision to previous application <br /> State Plan I.D.Number <br /> I. APPLI ATI N INFORMATION- PLEASE PRINT ALL INF RMATION I 3Ra <br /> Pro pe yOw er Name -/_ G^ Aroperty'Location <br /> P2 n �a y T1'� lT.�r/4 �, 1/4,5 �-� T � ,N, R /7E(org' <br /> Property Owner's Mailinlg A,ddressn ( Lot Number Block Num r <br /> 10 -73`1 <br /> City,State Zip Code Phone Number Subdivision Name or 5M Number <br /> 11. TYPE OF BUILDING: (check one) ❑ State Owned O Ity Nearest Road <br /> Public 1 or 2 Famil Dwellin -No.of bedrooms L] village _{ /� <br /> own O A--j/ <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo 60 b A� o 7 j acD <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. E] Replacement 3. [:] Replacement of 4. [:] Reconnection oE]f 5. Repair of an <br /> - __-_SystemSystem Tank O <br /> --------------------------------------------- -- ON ------------- Existing System ExistingSystem <br /> stem <br /> -------------- - ---- <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;9Mound 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 /> ��t� Re ulred(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) qct Elevation <br /> 2s S l� Z ! / y Feet /D?,2 Feet <br /> VII. TANK Capacity <br /> INFORMATION in gallons Total #of Manufacturer's Name Prefab. Con Fiber- Plastic Exper. <br /> New Existin Gallons Tanks Concrete Steel glass App. <br /> str)Cted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank �D!> A/1 6,O D ❑ <br /> Lift Pump Tank/SiphonChamber Leo 1 ❑ ❑ Q ❑ Q <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:(Pri t) Plumber's Signature:(N Stamps) MP/MPRSW No-: Business Phone Number: <br /> Plumber's Address(Street,City,�tate,Zip Code): <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (Includes Groundwater ate ssue Issuing A en Signa re(N ps) <br /> roved Surcharge Fee) <br /> PP ❑Owner Givenlnitial a� � � <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.11/97) DISTRIBUTION: Original to County.One copy To: Safety 8 Buildings Division,Owner,Plumber <br />