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Safety and Buildings Division <br /> *Lconsin SANITARY PERMIT APPLICATION 201 W.Washington Avenue <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 <br /> than 812 x 11 inches in size. Lt ) h 2 T a <br /> • See reverse side for instructions for completing this application state sanitary Permit NuIrnber WPersonal information you provide may be used for secondary purposes �5�ls� <br /> [Privacy Law,s. 15.04(1)(m)]. ❑Check it revision to previous application V I <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL IN RMATION <br /> Property Owner Nam Property Location <br /> R F 12 h •S^F 1"4 Y� ( <br /> 491/4 jJ E 1/4,S T 3 N, R I fer <br /> Pro erty Owner's Mailing Addres Lot Number Block Number <br /> s � Td <br /> City,Stat L� IPK Zip Coe Phone Number Subdivision Name or CSM Number <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ It Nearest Road <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms ❑ Village j <br /> Town OF /i't i?I )1 �,4+j, /2� <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(!�s))/ <br /> ❑ T <br /> 1 Apartment/Condo 0!!�—S S 3— © 4;)-- O <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 /> S ❑ 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. X 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(R 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: )12,5' Si -e w;-i �er _TA1414 vs <br /> 1. Gallons Per Day 2. Absorp.Area3. Absorp.Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Fina] Grade <br /> U Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> —/� S6� o b3 o C79q Feet <br /> VII. TANK Capacity <br /> INFORMATION in gallons Total #of Manufacturer's Name Prefab Site Fiber- Plastic Exper. <br /> New Existin Gallons Tanks Concrete Con- Steel glass App. <br /> Tanks Tanks strutted <br /> Septic Tank r Holding Tank 'WO 12-00 ) r ® 0 11 <br /> Li Pump Tank/Siphon Chamber I El Q El I El Ej <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibi ity for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name-(Print) Plu ber's S nature ( Stamps) =:S <br /> Business Phone Number: <br /> bels r t,l iS �6- goo <br /> Plumber's Address(Street,City,St e,Zip Code): , <br /> l ci b <br /> IXX::q <br /> COUNTY/DEPARTMENT USE ONLY o <br /> ❑Disapproved Sanitary Permit Fee (Includes GroundwaterT <br /> e ssue Issuing Agent Signature(No Stamps) <br /> ❑Owner Given Initial Surcharge Fee) t 1 <br /> Adverse Determination /7s• � 1(0-y7b ✓� IQG j Z <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 />