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" C! Y - Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> Aisconsin 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 <br /> than 8112 x 11 inches in size. % �j <br /> • See reverse side for instructions for completing this application State Sanitary Permit <br /> ['NTu/f'8ber <br /> Personal information you provide may be used for secondary purposes ❑Check if revision Iprevious application <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Numbe <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION I I QQ 0-39 <br /> Procieuv,Owner Name Property Location <br /> 1/4 114,5 is T ,N,R 15 E(or <br /> Property Owner's Mailing Address Lot Nu ber Block Number <br /> S %-j4 L.-14 - 4—.5 <br /> Ci State Li Code Phone Nu ber Su ivision Name or CSM Number <br /> &HoRElil e- l M4 . S 26 ((�12,) !-Q S1 r!I <br /> II. P ING: (check one) ❑ State Owned ';7— It) �,� �� Nearest Road <br /> Vllfage <br /> Public 1 or 2 Famil Dwelling-No.of bedroomsTown of <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel T lTaxNum/beerr((s) <br /> 1 E] Apartment/Condo 0IZ" 06 01 SMD <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. x 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❑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 13. Absorp.Area 4. Loading Rate 15. Perc. Rate 16. System Elev. 7. Final Grade <br /> Req red(sq.ft.) Proposed(sq.ft.) (Gals/d /sq.ft.) (Min./inch) flj, S Elevation <br /> SDO .900 ,f2 ~' 192.4 11OFeet � Feet <br /> VII. TANK Capaclt in allons Total #of Prefab. Site Fiber- Exper. <br /> New Existin strutted <br /> INFORMATION g Gallons Tanks Manufacturer's Name Concrete con- steel glass Plastic App- <br /> Tanks <br /> Pp <br /> T nks T— V1nks <br /> Septic Tank or Holding Tank "�� El El 1 <br /> Lift Pump Tank/Siphon Chamber E <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 Signature(N tamps) MP/MPRSW No.: Business Phone Number: <br /> tuMRn 145 Zb <br /> PI mber's Address jsttreet,City,State, Ot <br /> 21- b W[,I 1. qt <br /> IX. COUNTY/DEPAKTMENT USE ONLY <br /> [:]Disapproved Sanitary Permit Fee (Includes Groundwater ate ssue Issuing Ag t natur No a ) <br /> loved &.. ,charge Fee) <br /> p []Owner Given Initial (��� <br /> g—/ <br /> Adverse Determination ! <br /> X. CONDITIONS OF APPROVAL/REASONS FORDISAPPROVAL: <br /> SBD-6398(R.11/97) DISTRIBUTION: Original to County.One copy To: Safety a Buildings Division,owner,Plumber <br />