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`��` Safety and Buildings Division <br /> �.iSCOnSih SANITARY PERMIT APPLICATION 201 E.Washington Ave. <br /> In accord with ILHR 83.05,Wis.Adm.Code P.O.Box 7969 <br /> Department of Commerce Madison,WI 53707-7969 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County <br /> than 8 1/2 x 11 inches in size. l,. <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> The information you provide may be used by other government agency programs ❑Check it revision to previous application <br /> [Privacy Law,s. 15.04(1)(m)1_ State Plan I.D.Number J <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION <br /> Pro erty Owner Name 1 P erty Location <br /> 1/4,S 2& T Ve ,N, R/Y E(or <br /> Property Owner's Mailing Address 3 Lot Number/ Block Number <br /> a ' ' <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> L41 r W 5-vr!r 1% ( > J��3s/ ✓ 6-jO a 2 0 f-r.X.2 l <br /> TYPE F BUILDING: (check one) ❑ State Owned It Nearest Road <br /> SC P Q <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms IPE] Village <br /> Town of 4 <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo ©ag— <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 C] 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.;g 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 WMound 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 S. Perc. Rate 6. System Elev. 7. Final Grade <br /> Re wired(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) / Elevation <br /> J.0 d C �S� 4 1 .79.! Feet Dpi Feet <br /> VII. TANK Capacltallons Total #of Prefab. Site Fiber- Exper. <br /> in <br /> INFORMATION g Gallons Tanks Manufacturers Name Concrete con- Steel glass Plastic App <br /> New Existin structed <br /> Tanks Tanks <br /> Septic Tank or Holding Tank ,r 25--o A El El 11 0 0 <br /> Lift Pump Tank/Siphon Chamber OO JS ❑ ❑ ❑ I ❑ <br /> 1-1 <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:(No Stamps) MP/MPRSW No: Business Phone Number: <br /> Plumber's Ac dress(Street,City,State,Zip Code): <br /> .Qom S/ s,r-e- %j G./ �- <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> E]Disapproved Sanitary Permit Fee (Includes Groundwater Datelssued Issuing Age tS natur (NoS a s) <br /> Approved SujSh2(ge Fee) <br /> pp ❑OwnerGivenInitial �x, ov Adverse Determination Determination v�'� <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.11196) DISTRIBUTION: Original to county.One copy To: Safety&Buildings Division,Owner,Plumber <br />