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0 <br /> �is�consin <br /> SANITARY PERMIT APPLICATION 2oiew�n�9tonAve glen <br /> Department of Commerce In accord with Comm 83.05,Wis.Adm.Code P O Box 7302 <br /> Madison,WI 53707-7302 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less county, 02S� <br /> than 8 112 x 1 1 inches in size. 13 <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 1 revision to prews'application <br /> (Privacy Law,s. 15.04(1)(m)]. Staten I.D.Numyer <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION of� / <br /> Q.- <br /> Property Owner Name / Property Location <br /> e ¢ h,e! 5 C-114 5j5 1/4,S 3 1 T file ,N, R E(010 <br /> Property Ow rs Mailin Address Lot NumberBlock Number <br /> 4.7 Ll 670un c� L <br /> Cit State Zip Code Phone Number Sub �visionNameorCSMNumber <br /> "baK o ( � 7f� r L"b I VtS <br /> II. BUILDING: (check one) ❑ State Owned ^� City Nearest Road <br /> e I <br /> El Public 1 or 2 FamilyDwelling- No.of bedrooms —7 Town OF C <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(ss)) <br /> 1 ❑ Apartment/Condo 1 a " / 0 O Ofd <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. 151 New 2. ❑ Replacement 3_ ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> ------System ---- __System ___-_____ __ TankOnly___________ _ 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 Pressureqq 42❑Pit Privy <br /> 13 E]Seepage Pit 1"1T GYre A_QL_ 43❑Vault Privy <br /> 14❑System-In-Fill <br /> VI. ABSORPTION SYSTEM INFORMATION: <br /> 1.Gallons Per Day 2. Absorp.Area3. Absorp.Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade <br /> Required(sq.ft.) Proposed Min./inch)(sq.ft.) (Gals/day/sq.ft.) ( Elevation <br /> `t 5 O -7S_0 Feet Feet <br /> Capacit <br /> VII. TANK in allons Total #of Prefab. Site Fiber- Exper. <br /> INFORMATION Gallons Tanks Manufacturers Name Concrete Con- steel Plastic p <br /> New Existing structed glass App. <br /> T nits Tanks <br /> Septic Ta or Holding Tank /006be r Ea ❑ ❑ ❑ ❑ ❑ <br /> ft Puml Tank/Siphon Chamber Iri 1 19 El El 0 Ej El <br /> RESPONSIBILITY STATEMENT I &0-v �Jd — <br /> I,the undersigned,assume responsibilIity for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name:( rint) Flu e/r's�Si_gnatur tamps) MP/MPRSW No: Business Phone Number: <br /> P umber's Address(Street,City,State,Z" <br /> Code): ' /� <br /> 9& W K//_ YLj,r <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (Includes Groundwater ate IssuedA n Issuing ignat a(No to s) <br /> Approved E]Owner Given Initial / / Surcharge Fee) —� <br /> Adverse Determination _ <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.4/99) DISTRIBUTION: Original to County,One copy To: Safety 8 Buildings Division,Owner,Plumber <br />