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Safety an�Division <br /> ViSANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> sconsin In accord with ILHR 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 County <br /> than 8112 x 11 inches in size. 13uapJar <br /> • See reverse side for instructions for completing this application State Sanitary Permit 35Number <br /> ag3 <br /> Personal information you provide may be used for secondary purposes ❑Check it revision to previous application <br /> [Privacy Law,s. 15.04(1)(m)]- State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION <br /> Propel1y.Sivner Name Property Location <br /> I�AMLS 1/4 1/4,S Z5 T40 ,N,R 6 E(or <br /> Property wner's Mailing Address Lot Number Blgck.Plymber <br /> 52 4%4 Sr 3 G-L-3 <br /> City, tate Zip Code Ph ne Number SubdVIOL. <br /> ision Name or CSM Number <br /> ST. ALLL M N, S 2 ((PSI)174- j 98 -�II. TYPE OF B ILDIN : (check one) ❑ State Owned ❑ iNearest Road <br /> ❑ Village <br /> Public a 1 or 2 Family Dwelling-No.of bedrooms 2' Town CIF 6fzll <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo DIZ 4ZZS 64 MD <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 2.10 Replacement 3, ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> stem <br /> --___System ____--__System _____________ Tank Only_____---______ Existing System __-______Existing----t--- <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�g 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 /> Feet Feet <br /> TANK Cacit <br /> VII. INFORMATION in gallons Total #of Manufacturer's Name Prefab. Conite- steel Fiber- Plastic Exper- <br /> New ExistingGallons Tanks concrete strutted glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank N ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ <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:(Nost ps) MP/MPRSWNo.; Business Phone Number: <br /> tc}fARO 40V1411-j.51 944-4a <br /> Plu ber'sAddress(Street,City,State,ZipCode): IF <br /> 36 t,/r6sT6z I.Wi. -S489.3 <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (includes Groundwater ate IssuedIssuing gent Signature(No Stamps) <br /> pproved F-1OwnerGiven Initial Surcharge Fee) I'n <br /> Adverse Determination -A 0IS e 00 <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398 IRA 1/97) DISTRIBUTION: Original to County.One copy To: Safety a Buildings Division,Owner,Plumber <br />