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Visconsin <br /> SANITARY PERMIT APPLICATION 201eW.Washingt n Avenuen P O Box 7302 <br /> Department of Commerce In accord with Comm 83.05,Wis.Adm.Code Madison,WI 53707-7302 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County 1 <br /> than 81/2 x 11 inches in size. <br /> • See reverse side for instructions for completing this application St to Sanitary Per it Number <br /> Personal information you provide may be used for secondary 53 d W <br /> Y p Y ry purposes ❑Check if revision to previous application <br /> (Privacy Law,s. 15.04(1)(m)]. State PlanNu ber / <br /> I. APPLICATION INFORMATION- PLEASE PRINT ALL INFORMATION 67 S-Z I ,� <br /> Property Owner Name Property Location �}J <br /> L E 1/4 jq 1/4,S � T 39 •N, R 16 E(or)® <br /> Property Owne Mailing Address Lot Number Block Number <br /> City State Zig Code Ph ne Number Subdivision Name or CSM Number <br /> it 1,JI . 5429:5 11151u, S <br /> II. TYPE FBUILDING: (check one) ❑ State Owned L] City Nearest Road <br /> ❑ To age �J0`•t �►�OCJ I4E <br /> Public 1 or 2 FamilyDwellingNo.of bedrooms _ Town of ry <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo 01% 33rig OZ <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. E] Replacement of 4. E] Reconnection of 5_ [:] 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 21 MIMound 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 S. Perc. Rate 6. System Elev. 7. Final Grade <br /> A^�Zn^ Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> "C7lJ 15 _ 1 '~ 97 .] Feet 9.35 Feet <br /> aclt <br /> VII. TANK in Ca gallons Total #Of Prefab. Site Fiber- plastic Exper. <br /> INFORMATION New Existin Gallons Tanks Manufacturers Name Concrete Con- Steel glass App. <br /> Tank Tanks strutted <br /> Septic Tank or Holding Tank 112yo 12,10p ( GP 2 n n ❑ 0 <br /> Lift Pump Tank/Siphon Chamber S001 -- 1 9 ❑ ❑ ❑ ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumbers Name:(Print) Plumber's Signature:(No amps) MP/MPR5W No.: Business Phone Number: <br /> ,4ap 22 S 9 s I -11s- SGb- +s 1 <br /> PI mber's Address(Street,City,State,Zip Code): <br /> E WI - 94-S93 <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved nitary Permit Fee (Indudes6roundwater ate ssue Issuin antSig atur (N tamps) <br /> �pproved E]Owner Given InitialDQSur`bargeree)Adverse Determination <br /> co <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.4/99) DISTRIBUTION: Original to County,One copy To: Safety&Buildings Division,Owner,Plumber <br />