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Saf <br /> ty and <br /> on <br /> SANITARY PERMIT APPLICATION 2018E.Washington Ave. <br /> Visconsin 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 8112 x 11 inches in size. 4 9 <br /> • See reverse side for instructions for completing this application State Sanitary <br /> jPermit Number <br /> The information you provide may be used by other government agency programs ❑Chec�rew'sion to broils application <br /> (Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Name Property Location <br /> /'/77 e-J 114 1/4,S 7 T 5161 ,N, R/,/ E(or W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 2D /e ( r 1_�2 1;?, <br /> City,State Zip Code Phone Number Subdivision Nar�a or{-SRAi�fD per , <br /> io6vs �e N- 37 ((�>d' -a/z� rcAv� 1er / �sAgF717 <br /> Ill. TYPE 0F BUILDING: (check one) ❑ State Owned ❑ City Nearest Road <br /> Cj Public 1 or 2 Family Dwelling-No. of bedrooms I Town OF r1 nJr� Fs �-��w �I t��✓ <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo 1 0 aC 135- 05 <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. MNew 2_ [:] Replacement 3. E] Replacement of 4. [:] Reconnection of 5. ❑ Repair of an <br /> ____System __-_--__ _____________ <br /> System Tank Only Existing System _________Existln-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 KSeepage 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 /> G Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> 97<9 Feet <br /> Ca act <br /> VII. Site <br /> FORMATION in gallons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- plastic Exper <br /> New Existin Gallons Tanks Concrete structed glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank r vo ts ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber e Ceo ❑ ❑ ❑ ❑ ❑ <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:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> Plumber's Ac dress(Street,City,Statp,Zip Code): <br /> cs <br /> -S_1< � &d -V <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (IndudesGroundwater ffTtTe ssue Issuin ge t Sign r No Stamps) <br /> XApproved I lure e F )❑Owner Given Initial �fJ --f/ <br /> Adverse Determination <br /> . CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-639B(R.1196) DISTRIBUTION: Original to County.One copy To: Safety 8 Buildings Division,Owner,Plumber <br />