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Safety and Buildings Division <br /> Aisl6onsin SANITARY PERMIT APPLICATION 201 E.Washington Ave. <br /> In accord with ILHR 83.05,Wis.Adm.Code P.O.Box 7969 <br /> Department of Commerce Madison,WI 53707-7969 <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. Ay 1,,4j ap� Dj <br /> • See reverse side for instructions for completing this application tate sani�y Per it N ber <br /> The information you provide may be used by other government agency programs ❑Check i revision to pre ious application <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Nuhn}pr <br /> 1. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION /LTL <br /> Property Owner Name Property Location <br /> C ,Q f 1/4 1/4,S Q� T L16 ,N, R /:5—E(or <br /> Property Owner's Mailing Address k1 Lot Number Block Number <br /> SOI C I-A) i////e *4 .709 — <br /> I,State Zip Code Ph ne Number Subd v s Name or CSM Number <br /> y/`N u.,l/e Aoo , s 3 ( /.2 ) -,zj,/67 V/`/ 9_ I v <br /> II. TYPE F BUILDING: (check one) ❑ State Owned 0 City Nearest Road <br /> Public 1 or 2 Family Dwelling-No- E]of bedrooms °� Vown of ASS®nJ <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) / p <br /> 1 E] Apartment/Condo 0/; — a'� 7�/ ' © t�� 0 G0 <br /> 2 ❑ Assembly Hal] 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. C4 Replacement 3. ❑ Replacement of 4. ❑ 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 ❑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 Per Day 2. Absorp.Area 3. Absorp.Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 17. Final Grade <br /> ^� Reqy�red (sq. ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> �! O (� 4 ©C7 6ov S- -- �IGl2 Feet s'r,46� Feet <br /> Capacity <br /> VII. INFORMATION in gallons Total #of Manufacturer's Name Prefab- Con- Steel SiteFiber- Plastic Exper <br /> New Existin Gallons Tanks concrete structed glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank r,00 octpv ❑ ❑ ❑ ❑ ❑ <br /> Lift PumpTank/Siphon Chamber ❑ ❑ 01 ❑ ❑ ❑ <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:( Stamps) MP/MPRSW No.: Business Phone <br /> Phone Numbeerr:/ <br /> Plumber's Ac dress(Street,City,State,Zip Sode): <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved S�q Itary Permit Fee (Includes Groundwater a e ssue Issuing g t Signature(N to ps) <br /> Approved ❑ ` &Owner Given Initial / 7S argeFee) / /Dq <br /> Vp Adverse Determination —� <br /> X. CONDITIONS OF APPROVAL/REASONS FOR APPROVAL: <br /> SBD-6398(R.11/96) DISTRIBUTION: Original to County.One copy To: Safety&Buildings Division.Owner,Plumber <br /> l <br />