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z— <br /> Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> `Visconsin In accord with ILHR 83.05,Wis.Adm_Coe P O Box 7302 <br /> Code Department of Commerce Madison,WI 53707-7302 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less Cou <br /> than 8 1/2 x 11 inches in size. ew "P— <br /> • <br /> • See reverse side for instructions for completing this application State Sanitary Permit � ation <br /> r U) <br /> O <br /> Personal information you provide may be used for secondary purposes Chec;011f5e�vision io evlous a lic <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATI N p� <br /> Propeer Name 1 Property Location <br /> Le � e 1/4 1/4,S T yQ ,N, R/,j E(orX@ <br /> PropertyO _ 0'e.Owner's Mailing AddressS Lot Number Block Number <br /> hi <br /> ty,State IOZip CodePhone Number Subdivision N me or CSM Numb r <br /> )ate-9y a <br /> II. TYPE Of; BUILDING: (check one) E] State Owned o village Nearest Road <br /> r ; 79?5— <br /> Public 1 or 2 Family Dwelling-No.of bedrooms Town OFJ,4r-ks KdVAxil� <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo 0/01 '7'a,S ® S 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. j&Replacement 3_ ❑ Replacement of 4_ ❑ Reconnection of 5. ❑ Repair of an <br /> ------ --------_______System ------------- Tank Only---_---__---_- Existing System _-_---___E----tin-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 VtSeepage 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 Per2. Absorp.Area 3. Absorp.Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade <br /> Re wired(sq.ft.) Proposed(sq.ft.) (Gals/da /sq.ft.) (Min./inch) C�/� Elevation <br /> '300Day ?,b 600 s "— /Gf 3 Feet Feet <br /> Ca c <br /> VII. INFORMATION in gallo s Total #of Manufacturer's Name Prefab. Con Steel Fiber- Plastic Exper- <br /> New Existin Gallons Tanks concrete structed glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank gBd — Igo S�i4 rcJ ❑ ❑ ❑ ❑ ❑ <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:(No Stamps I MP/MPRSW No.: Business Phone Number: <br /> Gc)A-W— qa! 1 ��7� <br /> Plumber's Address(Street,City,State,.Zip Code): _ / ,moi <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved y Permit Fee (IndudesGroundwater ateIssued Issuing Agent S nature \10 <br /> harge ree) <br /> �,4pproved ❑Owner Given Initial _ "7S a t <br /> vv Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FORDISAPPROVAL: <br /> SBD-6398(R.11/97) DISTRIBUTION: Original to County,One copy To: Safety 8 Buildings Division,Owner,Plumber <br />