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Safety and Buildings Division <br /> i`, SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> Visconsin In accord with ILHR 8305Wis.AdmCode P O Box 7302 <br /> . , . . <br /> Department of Commerce Madison,WI 53707-7302 <br /> 0 Attach complete plans(to the county copy only)for the system,on paper not less County„ <br /> than 8112 x 11 inches in size. 6 e/ -e-71061A3301 <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> Personal information you provide may be used for secondary purposes ❑Check it r3evision 10 pre sous application <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number Q <br /> I. APPLICATION INFORMATION- PLEASE PRINT ALL INF RMATION 6_0 �S <br /> PropeOw er Name Property Location <br /> D �, @ r.-v 5 .4 ,e r 114 114,S T y0,N, R Ifi E(or W <br /> Property Owner's Mailing Address Lot Numbpr Block Number <br /> /S 41-) e. c 65; L. <br /> Ci ,State Zip Code I Phone Number Subdivision Name or CSM Number <br /> F W o :za <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned City Nearest Road <br /> ❑ Village / �� <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms Town of 0�� Atidd''- dd"' i 5' cis <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s)c/ / <br /> 1 ❑ Apartment/Condo L.0 a a 733/ 4 Scs v <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. Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> System Replacement <br /> ----- Tank Only _ Existing System -------- Existln�S�rstem <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 ❑Mound 30❑Specify Type 41 4KHolding 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 /> Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> ,_ll ~ Feet Feet <br /> Ca aclt <br /> VII. TANK In gall0 S Total #Of Prefab Site Fiber- Plastic Exper. <br /> INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass App <br /> New Existin structed <br /> Tanks Tank / <br /> 9*V"l:TartkorHolding Tank d �4d � G✓ ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ El 13 ❑ El <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 /> �C Gin rC- �7d 1c7.vyP- 711-4C <br /> Plumber's Address(Street,City,Statef.Zip Code): ' / <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Issuing A e Signa (N S <br /> VA roved / r rge Fee) �G <br /> 1 , pp [-]Owner Given Initial <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.11197) DISTRIBUTION: Original to county.One copy To: Safety 8 Buildings Division,Owner,Plumber <br />