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• SANITARY PERMIT APPLICATION Safety and Buildings Division <br /> isconsin 201 W.Washington Avenue <br /> In accord with ILHR 83.05,Wis.Adm.Code P a Box, 302 <br /> W1 <br /> Department of Commerce Madison,WI 53707-7302 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less Co unt <br /> than 81/2 x 11 inches in size. e4,/1/ 7 e <br /> • See reverse side for instructions for completing this application State Sanitary Permit.Number d <br /> Personal information you provide may be used for secondary purposes ❑Check if revision o p iotas application <br /> [Privacy Law,s. 15.04(1)(m)]. <br /> State Plan I Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION <br /> Property OwnerNa � Property Location <br /> gA /� /4,S T ,N, R E(orW <br /> Property Ciner's Mailing Address <br /> - Lot Number �i Block Number <br /> cP 3 --2p /C.,itJ e 1 — Gr � ZS <br /> Cit ,State Zip Code Phone Number Subdivision Name or CSM Number <br /> II. TYPE OF BUILDING: (check one) ❑ State OwnedIts Nearest Road <br /> ❑ Vil age / 2 / <br /> Public or 2 FamilyDwelling-No.of bedrooms own OF � �a!/� //lOicJ e- <br /> III. BUILDING USE: (If building type is public,check ail that apply) Parcel Tax Number(s) c� <br /> 1 ❑ Apartment/Condo O L/ �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. 15�- -- --___Replacement 3, [:] Replacement of 4. E] Reconnection of 5_ E] Repair of an <br /> ------ ---___ _''_`---stem ------------- Tank _-___--_ Existing System -__-_-__ Existing <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 E(lound 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) Elevation <br /> V _-_2 5—0 oZ S�� /1 ;), I ;�',,.3 Feet /0/1 Feet <br /> Ca ct <br /> VII. INFORMATION in gallons Total #of Manufacturer's Name Prefab Con steel Fiber- Exper <br /> New Existin Gallons Tanks Concrete glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank /,1'S'D 2— ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber I 1jil- ❑ ❑ ❑ ❑ ❑ <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 N me:(Print) /� Plumber's Signature:( o Stamps MP/MPRSW NNo.: Business Phone Number: <br /> P umber's Address(Street,City,State,Zip Code): <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Issuing Agen Si nature No s) <br /> fAcpproved InOwner Given Initial � of Surcharge Fee) <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.11/97) DISTRIBUTION: Original to County,One copy To: Safety 4 Buildings Division,Owner,Plumber <br />