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0-n6 <br /> ��, Safety and Buildings Division <br /> con5in SANITARY PERMIT APPLICATION 201 P.O. .Washington Ave. <br /> �ris <br /> Department of Commerce In 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 Count <br /> than 81/2 x 11 inches in size. zs/-�,Je, <br /> • See reverse side for instructions for completing this application State Sanitary <br /> Permit Numbersw <br /> The information you provide may be used by other government agency programs ❑Check ir3revi vious application <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.NumWer <br /> 1. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION <br /> Property Owner NameProperty Location <br /> ` x � //C r,J 2,; 1/4/ IF 1/4,S J2 T39 ,N, R E(or) <br /> Property Owners Mailing Address Lot Number Block Number <br /> ICity,State Zip Code Phone Number Subdivision Name or CSM Number <br /> IwJeZ ;r 6jrd ( ) 1 <br /> ll. TYPE 0F B ILDING: (check one) ❑ State Owned ❑ ity q Neares Road <br /> ae <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms 3 C, Tolwn OF L�iuc d >?��� e. <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo C D/ -.�, Q <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. (KNew 2. ❑ 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 A Seepage 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 /> Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) c Elevation <br /> Feet 97� Feet <br /> TANK Capact <br /> VII. INFORMATION in gallons Total #of Manufacturer's Name Prefab. Con- Steel ite Fiber- plastic Exper <br /> New ExistingGallons Tanks concrete strutted glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank loeol ilrec) Z 13 ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber I I I ❑ ❑ ❑ ❑ ❑ ❑ <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 Stamp MP/MPRSW No.: Business Phone Number: <br /> Plumber's Ac dress(Street,City,State,Zip Code): <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuin AaentSi re(N <br /> J�mpproved ❑ charge Fee)Owner Given Initial / �� _0-3-� <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FORDISAPPROVAL: <br /> SBD-8398(R.11y96) DISTRIBUTION: Original to county.One copy To: Safety 8 Buildings Division,Owner,Plumber <br /> I� <br />