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I . �� <br /> L5 Safdty and Buildings Division <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> %60nsin P O Box 7302 <br /> In accord with ILHR 83.05,Wis.Adm.Code Madison,WI 53707-7302 <br /> Department of Commerce <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County <br /> than 81/2 x 11 inches in size. C/ <br /> Z �U <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 ❑chcicklRevisi�to p e/.us application I <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Numb t7-1 <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION <br /> Property Owner Name Property Location <br /> tJ $f_1/4 RQ 1/4,S 13 T ? ,N,R 6 E(orXWJ <br /> Property Owner's Mailing AddriAs Lot Number Block Number <br /> 2 N. OXFoRp <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> T, L u i 3 (G 12-) '-3201 i ACRES <br /> II. Y ILDI : (check one) ❑ State Owned ❑ qty Nearest Road <br /> 2 ❑ VIl age ffWO t CO. TJ,,. X <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms Town OF TSS N 1. JZD <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo CIS 331$ 0::—" (000 <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.)4 Replacement 3_ E] Replacementof 4. E] Reconnection of 5. E] 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 ❑Seepage Bed 21AMound 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. 17. Final Grade <br /> Required(sq.ft.) Propose (sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> 300 25 Q2 ZZ l• 2 <br /> 01-7, 1 Feet $ Feet <br /> VII. TANK Capacity site <br /> in gallons Total #Of Manufacturer's Name Prefab. Con- Steel Fiber- plastic Aper. <br /> INFORMATION New Existin Gallons Tanks concrete strutted glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank riso I V 11,61) ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber 5bo I - <br /> 500 r ❑ ❑ ❑ ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> [,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 nips) MP/MPRSW No.: Business Phone Number: <br /> n!S " 1 lis- $ 6- S7 <br /> PI mber's Address(Street,City,State,Zip Code) <br /> 217 (oo f4= Uf4Eas <e tj(. s 4gl's <br /> IX. COUNTY/DEPARTIMENT USE ONLY <br /> E]Disapproved Sanita Permit Fee (Includes Groundwater ra,]tesueIssuing ge Sign ure mps) <br /> prove291 <br /> ❑Owner Given Initial D �u rgeree) <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(8.11/97) DISTRIBUTION: Original to county.One copy To: Safety 8 Buildings Division.Owner,plumber <br />