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and <br /> dings <br /> SANITARY PERMIT APPLICATION 201eW.WasBhingt n Avenuen <br /> Visconsin In accord with(LHR 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 Couy <br /> than 8 112 x 11 inches in size_ w-/4� O��b <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 E]Check i agi won to Pr�us plication <br /> (Privacy Law,s. 15.04(1)(m)). State Plan I.D.Nu <br /> 1. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATI N Sa e� b <br /> PropertyOvine (Name Property Location � <br /> ei /_ r5eA) 1/4 1/4,535- T39 � <br /> ,N, R� E(oCW <br /> PropertyOwner's Mailing Add ess Block Number <br /> o.5 w ao �f� L -Zj ti c.tJ G,L -Z <br /> CityJtate / Zip Code Phone Number Subdivision Name or CSM Number <br /> /117/u I t fo 6_07 <br /> 11. 1 YPLILD N : (check one) ❑ State Owned City Nearest Road <br /> Public 1 or 2 Famil Dwellin -No.of bedrooms ; ❑ O age C� � 4� <br /> wn OF ¢ <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo <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.XReplacement 3. ❑ Replacement of 4. ❑ Reconnection of 5, ❑ Repair of an <br /> ------System --------System ____ Tank Only---------------ExistinciSystem ____ ___ ExlstingSystem <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 1317ioldi ng 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.Area3. 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 /> Feet Feet <br /> VII. TANK Capacity <br /> INFORMATION in gallons Total #of Manufacturer's Name Prefab. Con-Site Fiber- plastic Exper <br /> New Existing Gallons Tanks Concrete steel glass App. <br /> Tanks Tanks <br /> ank strutted <br /> Septic Tank or Holding Tank add dC) ❑ <br /> Lift Pump Tank/Siphon Chamber El El Q I El I E Q <br /> VIII. RESPONSIBILITY STATEMENT <br /> 1,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plum tier's Name:(Priry� Plumber's Signatur :(No S ps) P/MPR Business Phone N�2�� <br /> Plumber's Address(street,City,State, ipCode): <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (includesGroundwater ate ssue Issuing Agent Signature(No Stamps) <br /> A roved surcharge reel <br /> PP ❑Owner Given Initial � /� � <br /> Adverse Determination 1 <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.11/97) DISTRIBUTION: Original to County,One copy To: Safety&Buildings Division,Owner,Plumber <br />