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em, , <br /> Safety and Buildings Division <br /> ,• SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> `A1nCOnsin 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 3 <br /> than 8 112 x 11 inches in size. tz <br /> • See reverse side for instructions for completing this application Stale Sanitary Permit Number ��j g <br /> Personal information you provide may be used for secondary purposes ❑Check it revision t8{re us applicakn <br /> (Privacy Law,s. 15.04(1)(m)). State Plan I.D.Numb r G 1N <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION <br /> Property Owner Name qropert�/Location I 1/4,S 1 T 4 ,N, R ISE <br /> E(ore <br /> Property Owner's Mailing Addrets Lot Number Block Number <br /> 2.0 <br /> City,State Zip Code Phone Number Subdivisn Name or C M Nu ber <br /> Mil SS (6n) .Srn �• <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned n 'ty I Nearest Road <br /> ❑ Village E 1� <br /> Public Ig 1 or 2 Family Dwelling-No.of bedrooms 3 Town of <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo ol�— 4_ ,o 0 <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. [:] Replacement of 4. F] Reconnection of 5. E] Repair of an <br /> --__System _ _ System ___ _ ____ TankOnl�f ___ ___ Exist 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 /> 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 S. Perc. Rate 6. System Elev. 7. Final Grade <br /> Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> 454 43 3"16 1,7. Feet 93 Feet <br /> VII. TANK in Ca aaa <br /> tllons Total #of Prefab. Site Fiber- Exper <br /> INFORMATION g Gallons Tanks Manufacturers Name Concrete Con- steel glass Plastic App <br /> New Existin structed <br /> Tanks Tanks <br /> Septic Tank or Holding Tank 000 ❑ <br /> Lift Pump Tank/Siphon Chamber &M I A I &M El ❑ ❑ ❑ <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 Signatur :(N Stamps) MP/MPRSW No.: Business Phone Number: <br /> cH Ro 22,.585 -715-8fdo- 4.15-7 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 2'17(,o t4wj ag, b.11. S4 9 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved nitar Permit Fee (includes Groundwater ate ssue Issuing Age Signa re( ps) <br /> 'Approved ❑Owner Given Initial charge Fee) f�/� 11.1 <br /> Adverse Determination ("�(CJ�f 6 <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 />