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Safety and Buildings Division <br /> VjswnsiSANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> n In accord with(LHR 83.05,Wis.Adm Code P O Box 7302 <br /> h <br /> Department of Commerce Madison,WI 53707-7302 <br /> 4 Attach complete plans(to the county copy only)for the system,on paper not less County � <br /> than 812 x 11 inches in size. <br /> • See reverse side for instructions for completing this application 9Me sanitary permit Number <br /> 1 ��� (� <br /> Personal information you provide may be used for secondary purposes ❑Check it r sin r Ious application (n <br /> (Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number�� f nI <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION <br /> Prope y Owner Name Property Location <br /> �O 1/4 1/4,5 13 T40 N,R E(oreW <br /> Prope y Owner's Mailing Address Lot Num er NI a4• —4er <br /> D Z <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> ST• UL. M0. C) ( ) <br /> II. ILDING: (check one) ❑ State Owned ' L] ity Nearest Road <br /> village C C_ <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms Town OF .7 <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo Ms 4413 02- =0 <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. ❑ Replacement of 4. [:] Reconnection of 5. ❑ Repair of an <br /> System _ System _ _ _ Tank Only _ Existing System _- ExistingSystem <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 /> 11Seepage Bed 21 ❑Mound 30❑Specify Type 41 C]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.Area3. Absorp.Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade <br /> Required(sq.ft.) Pro osed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Q Elevation <br /> 45D 1q00 *5 !�. l Feet ID21.4 Feet <br /> a clt <br /> VII INFORMATION in gallons Total #of Manufacturer's Name Prefab. Con Steel Fiber- Exper. <br /> Gallons Tanks Concrete glass Plastic App <br /> New Existingstructed <br /> Tanksi Tanks <br /> Septic Tank or Holding Tank ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber % ❑ ❑ ❑ 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 St ps) MP/MPRSW No.: Business Phone Number: <br /> Z6 S <br /> P tuber's Ad ress(Str e ,City,St te,Zip Code): <br /> IX. COUNTY (DF ME - 'USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature(N S ps) <br /> -Approved ❑Owner Given Initial Surcharge Fee) <br /> Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> 5f�/ Seg/cue/r a �14inc�Qn��c� �IS¢'erVt�i�a <br /> WL�1 d� �e FCmoJe�L'�$ .S�n os /'aclli �W. <br /> SBD-6398 IRA 1197) DISTRIBUTION: Original to County, ne<apy To: Safety&Buildings Division,Owner,Plumber <br />