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' Safety a ' mgs Division <br /> `�SC0115►11 SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> In accord with ILHR 83.05,Wis.Adm.Code P O Box 7302 <br /> Department of Commerce Madison,WI 53707-7302 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County -7 <br /> than 8 112 x 11 inches in size. ttR L,-� I / <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> Personal information you provide may be used for secondary purposes ❑Check i(revision t p vious application <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION <br /> Property Owner Name Property Location <br /> MAW Ae-kERMAM 1/4 1/4,S j.2— T40 ,N, R 14 E(o W <br /> Property wner's Mailing Address Lot Number �el: <br /> Cit ,Stat Z' Code Phone Number Subdivi//sLsiJio--n Name or CSM Number <br /> o POvt ILII _ 1 .54-7 ( 15) -3 2S VO Z$Z - z <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ It� Nearest Road <br /> Public X 1 or 2 Family Dwelling-No.of bedrooms :7 °Tow9 of SC9P • A <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) __ <br /> 1 ❑ Apartment/Condo 02-S 4-MZ 03 q LO <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing H e 10 ❑ Outdoor Recr ational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise:Sales/Repairs Restau 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 S. ❑ 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 /> 1 1ASeepage Bed 21 ❑Mound 30 C]Specify Type 41 E]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. 7. Final Grade <br /> 4510767-1 <br /> , Req r d(sq. ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) p EI vati n <br /> O (C`t' (O'T f. �-- l.s• Feet �.(O Feet <br /> Ca aclt <br /> VII. TANK in gallons Total #of Manufacturer's Name Prefab. on Steel ite Fiber- Exper. <br /> INFORMATION Gallons Tanks Concrete glass Plastic App <br /> New Exist ng structed <br /> Tank TanksI �q <br /> Septic Tank or Holding Tank 000 --1, 11000 0 ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber I I ❑ ❑ ❑ ❑ I ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> ti <br /> Plumber's Name:(Print) Plum ber'j Signature:( St ps) MP/MPRSW No.: Business Phone Number: <br /> ct,jzp o , gni' 6C- S1 <br /> P mber's Address(Street,City,St t ,Zip Code): <br /> 7-1 <br /> ` ✓w l -g93 <br /> — �Q W. c-s t 1 GJz,{� <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit F@e (includes eFee)water ate IssuedIssuing Age ignature( S ps) <br /> roved Q�C Surcharge Fee) <br /> pp ❑Owner Given Initial � • �/ <br /> Adverse Determination <br /> CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> 48(R.11/97) DISTRIBUTION: Original to County,One copy To: Safety&Buildings Division,Owner,Plumber <br />