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*6consinSANITARY PERMIT APPLICATION 201Safety <br /> and ldins <br /> WshingtonADivsion <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 8 112 x 11 inches in size. Ts �� <br /> • See reverse side for instructions for completing this application s ate sanitary Per it tuber Q <br /> v <br /> The information you provide may be used by other government agency programs El check rf r` evTsion ro previous�aDpplication <br /> [Privacy Law,s. 15.04(1)(m)]. <br /> State Plan I.D.NurjtWr <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION <br /> Propyly Owner Name pert oc tion <br /> U /4 1/4,5 T N, R �JpE(orE::: <br /> Property Owner's Mailing Ad ress [�. p Lot Num er Block Number <br /> 1nj RI�i2 Rov Z <br /> CaL State Zip Code Phone Number Subdivision Name o SM Numbe �j <br /> 12 340 ( 1 (� <br /> 1 . TY F LDIN 1111 <br /> 3: (check one) ❑ State Owned it Nearest Road <br /> Public 1 or 2 FamilyDwelling- No.of bedrooms Z votl of <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax <br /> rrNNu�umbee�r(s) <br /> ❑ V`v <br /> 1 Apartment/Condo 4.307 01140 <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. E] Replacementof 4. ❑ Reconnection of 5. E] Repair of an <br /> ______System _ System ------------- Tank-Only--- xisting System Exist"ngS stem <br /> B) :KA 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 Xseepage 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 3. Absorp.Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade <br /> Requ'red(sq.ft.) P o osed(sq. ft.) (Gals/day/sq.ft.) (Min./inch) ElCyption <br /> 30O Z Z .2 '—' '9' Feet ,C7 Feet <br /> VII. TANKCapacity <br /> in gallons Total #Of Prefab Site Fiber- Exper <br /> INFORMATION New Existin Gallons Tanks Manufacturer's Name Concrete Cin Steel glass Plastic App <br /> strutted <br /> Tanks T nks <br /> Septic Tank or Holding Tank ----. Q El <br /> Lift Pump Tank/Siphon Chamber El ❑ ❑ I El El F1 <br /> Vill. 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: o5 ps) MP/MPRSWNo.: Business Phone Number: <br /> t 225$�'I JS- <br /> P[ mbei s A(dress(Street, it State,Zip Code): <br /> n E8 WJ. <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> []Disapprove tary Permit Fee (Includes Groundwater Fj <br /> te IssuedssuingAg tSign ur o mps) <br /> roved 7� Surcharge Fee) ��/`�pp ❑Owner Given Initial l(JT�J�\ [`/ <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(RA V96) DISTRIBUTION: Original to County.One copy To: Safety B Buildings Division,Owner,Plumber <br />