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Safety and Buildings Division <br /> `�SC011S%11 SANITARY PERMIT APPLICATION Po Bo��hinngtonAve. <br /> Department of Commerce In accord with[LHR 83.05,Wis.Adm.Code Madison,WI 53707-7969 <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. 3a 9 <br /> • See reverse side for instructions for completing this application State Sanitary 3n,#Number/ <br /> The information you provide may be used by other government agency programs ❑Check if revision to previous application <br /> [Privacy Law,s- 15.04(1)(m)]. State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INIF MATT N /V/T <br /> Property Owner N me r Property Location <br /> C f1 1C e-A) 1/a 1/a,S T �// ,N, R 16 E(or)�V <br /> Property Owner's Mailing Address NJ Lot Number Block Number <br /> 4y,?/ e- or, 0 <br /> Cit ,Stat Zip Code Phone Number Subdivision Name or CSM Number <br /> n3 i' a ( 5�7>S�3-YL� r c�� /fes, 77tN;Zest <br /> I. ING: (check one) E] State Owned 0 ity Road <br /> L1VillagePublic 1 or 2 Famil Dwellin - No.of bedrooms ' Town of <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo 103;2 5_-7�7 S� 0 ` p C) <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 1 ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> System _ystem 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 21 []Mound 30❑Specify Type 41 ❑ Holding Tank <br /> 12 QSeepage Trench 22❑In-Ground Pressure / 42❑Pit Privy <br /> 13❑Seepage Pit 12— �U � p 43❑Vault Privy <br /> 14❑System-In-Fill S <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./inc A . Elevation <br /> 006 1 -5 7� f:5 yC.7 Feet c 7. 5Feet <br /> Capacct <br /> VII. INFORMATION in allons Total #of Manufacturer's Name Prefab Con- Steel Fiber- plastic Exper <br /> New Existin Gallons Tanks Concrete strutted glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank 75 2v 1 a 1 ❑ ❑ I ❑ 1 ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ✓tlG) U ❑ ❑ ❑ ❑ ❑ <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) Plumbe 's Signature:(N tamps) MP/MPRSW No.: Business Phone Number: <br /> Plumber's A(dress(Street,City,State,Zip bode): _ <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (includes Groundwater ate IssuedIssuing Ag tSignature o tamps) <br /> 5 c ge Fee) 7/'p <br /> Approved ❑Owner Given Initial / Lam` __V_ <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.11/96) DISTRIBUTION: original to County.One copy To: Safety B Buildings Division,owner,plumber <br />