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SANITARY PERMIT APPLICATIO <br /> VisconsinInP.O.Box 7969 <br /> Department of Commerce accord with[LHR 83.05,Wis.Adm.Code 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. BvNillu7 <br /> • See reverse side for instructions for completing this application State Sanitary Permit/%NNumber <br /> The information you provide may be used by other government agency programs Elchf it r�sj E evious application <br /> [Privacy Law,s. 15.04(1)(m)). State Plan LD. um <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION <br /> Property Ow Name Property Location <br /> C" 1Z 010 l tys SE 1/4 $y1/1/4,S Zp T 37 ,N, R 16 E(orko <br /> Property Owner's Maili lLot Number Block Number <br /> City,StateZi Code C Phone Number Subdivision Name or CSM Number <br /> Jelg_Z <br /> II. TYPE F BUILDING: (check one) ❑ State Owned 0 f Ity Nearest Road <br /> ❑ Village <br /> Public 1 or 2 Family Dwelling- No.of bedrooms lid Town OF RROE LAKE 1060AC - LA1Jc <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 19 ❑ Outdoor Recreational Facility <br /> 3 V Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining <br /> 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station ACar Wash <br /> 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13M Other: specify ESoQ"' <br /> IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) <br /> A) 1_ ❑ New 2-teplacement 3, ❑ Replacement of 4. ❑ Reconnection of 5_ ❑ Repair of an <br /> -----System --------System ------ ------ Tank Only--- -- Existing System - Existing System <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 21XMound 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-[n-Fill <br /> VI. ABSORPTION SYSTEM INFORMATION: <br /> 1.Gallons Per Day 2. Absorp.Area 3. Absorp.Area 4. Loading Rate 15.Perc. Rate 6. System Elev. 7. Final Grade <br /> Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> 3)lt 2 Z <br /> � 594) // Z I 9'S, Feet Feet <br /> Capacity VII. TANK in gallons Total #of Prefab. Site Fiber- Plastic Exper <br /> INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- steel glass App. <br /> New Existingstructed <br /> Tanks Tanks q <br /> Septic Tank or Holding Tank � 10040 Z uxkss&2 ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber SINK — <1110 I I welue-2 19 1 ❑ Q El <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> lumber's Name:(Pr t) <br /> Plumber'�Signature: naps) M � Business Phone Number: <br /> /J v� 7 W (e 2– <br /> Plum ddress(Street,City,State,Zip Co ): <br /> G AV 5 S ar.— o <br /> IX- COUNTY/DEPARTMENT USE ONLY <br /> ("cudhFeee Isuin A ntS❑DisapprovSaniaryPerme ) n tF Stamps) <br /> ❑OwnerGivenInitial V curge <br /> pproved <br /> C/ <br /> Adverse Determination U `� <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SB04M(11 INS) oKTRIBUT1ow original to County,One copy To: Safety E Buildings Division,owner,Plumber _ <br />