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6-n cn-np <br /> Safety and Buildings Division <br /> VITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> mcons►n In accord with ILHR 83.05,Wis.Adm.Code P 0 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 <br /> than 8 vz x 11 inches in size. F,,pi� A/5 <br /> Permit Nu <br /> • See reverse side for instructions for completing this application Sanitary mberation ��5jr���c'�> <br /> Personal information you provide may be used for secondary purposes ❑CO i�revision to previous application v <br /> [Privacy law,s. 15.04(1)(m)]. <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION- PLEASE PRINT ALL INF RMATION <br /> Property Owner Name Property Location I <br /> 1/4 1/4,S T L <br /> ,N, R E(o W <br /> ProlfertyOwner's Mailing dress Lot Number Block Number <br /> 7.57 hRE M A R 0 <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> tt 1. 541,30 P.3o <br /> TYPE OF BUILDINU: (check one) ❑ State Owned Ity Nearest Road <br /> ❑ Village /¢�S��7] -` <br /> Public 1 or 2 Famil Dwellin -No.of bedrooms 2 lighTown OF e) f N(> lfsoisit5c <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) . x.07- I 13//{. / 09l«aidshy-199 <br /> 1 ❑ Apartment/Condo 20-g3j ,T-0I— 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 e 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 /> 1Seepage Bed 21 ❑Mound 30❑Specify Type 41 ❑Holding Tank <br /> 12 ,Seepage Trench 22❑In-Ground Pressure 42❑Pit Privy <br /> 1 ❑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 /> Required(s .ft.) Proposed(sq.ft.) (Gals/da /sq.ft.) (Min./inch) evation <br /> 30 O ? .2 13, (o Feet � .ZFeet <br /> Ca clt <br /> VII. TANK FORMATION in gallons Total #of Manufacturer's Name Prefab. Con- Steel Site Fiber- plastic Aper_ <br /> New Existin Gallons Tanks concrete structed glass App. <br /> Tanks Tank11 <br /> Septic Tank or Holding Tank L ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ f ❑ ❑ ❑ <br /> Vlll. 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 Signature:( o S ps) MP/MPRSW No.: Business Phone Number: <br /> te-AA12-P P nfs S- bb- <br /> Plu ber's Address(Street,City,Stateip Code): <br /> , <br /> lkL� 35- <br /> IX. COUNTY/ DEPART EN USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Ag nt gnatur (No s) <br /> A roved Syrrharge Fee) <br /> pp ❑Owner Given Initial /1 ly1r1� <br /> Adverse Determination 1 <br /> X. CONDITIONS OF APPROVAL/REAS NS FO I PROVAL: AP <br /> SBD-6398(R.11197) DISTRIBUTION: Original to County,One copy To: Safety 8 Buildings Division,Owner,Plumber <br />