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U /e"L "t-- rk- . <br /> Safety and Buildings Division <br /> 201 W.Washington Avenue <br /> `� <br /> SANITARY PERMIT APPLICATION P o Box 7302 <br /> fsConsin In accord with ILHR 83.05,Wis.Adm.Code Madison,WI 53707-7302 <br /> Department of Commerce <br /> • Attach complete plans(to the county copy only)for the system,on paper not IeiS County S <br /> than 8 v2 x 11 inches in size. r� <br /> State Sanitary Pets Number <br /> • See reverse side for instructions for completing this application [�/[./ o�'Cf.v�1-, <br /> Personal information you provide may be used for secondary purposes <br /> ❑Check if revision[o previous application <br /> [Privacy Law,s. 15.04(1)(m)). State Plan I.D.Num <br /> ber <br /> 1. APPLICATION INFORMATION-PLEASE PRINT ALL INF RMATI N <br /> Property Location N,R (6r <br /> Pr erty Owner Name ff�t/q w 114,S T <br /> r e 11Lot Number Block Number <br /> Property Owner's Mailing Add <br /> V <br /> City,Sta e f Zip(o�Je Phone Number Subdivision Name or CSM Num er <br /> 15 ('7!V - et vw S <br /> 1State Owned !ty Nearest Road <br /> I . PBUILDING: (check one) ❑ ❑Village dQ ft+G (` <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms � Parcel TazOF 0, r(s) <br /> III. BUILDING USE: (if building type is public,check all that apply) <br /> &=)-o - 91 1{o - o coo <br /> 1 ❑ Apartment/Condo10 Outdoor Recreational Facility 11 <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home ❑ Restaurant/Bar/Dining <br /> 3 E] Campground 7 C] Merchandise: Sales/Repairs ❑ <br /> Mobile Home Park 12 ❑ Service Station/Car Wash <br /> 4 F1Church/School 8 ❑ 13 ❑ Other: specify <br /> 5 ❑ Hotel/Motel 9 ❑ Office/Factory <br /> [A) <br /> TYPE OF PERMIT: (Check only one box on line A. Check box on line B,if a E] Reconnection of 5. ❑ Repair of an <br /> 1 New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Exlstln S stem <br /> S stem TankOnl ____ ________ Exlstinc�System __ ___________$_Y____ <br /> __ S_stem --y <br /> -y-------------y---------------------- Date Issued <br /> B) ❑ AS anitary Permit was previously issued. Permit Number <br /> V. TYPE OF SYSTEM: (Check only one) Other <br /> Non-Pressurized Distribution Pressurized Distribution Experimental <br /> 30❑Specify Type 41 f-1 Holding Tank <br /> 11 ® 21 Seepage Bed []Mound 42❑Pit Privy <br /> 12❑Seepage Trench 22❑In-Ground Pressure 43❑Vault Privy <br /> 13❑Seepage Pit <br /> 14❑System-In-Fill <br /> VI. ABSORPTION SYSTEM INFORMATION: 7. <br /> 1.Gallons Per Day 2. Absorp.Area 3. Absorp.Area 4. Loading Rate 5.Perc. Rate 6. System Elev. Elevlationrade <br /> Required(sq_ft.) Proposed(sq.ft.) (Gals/da q-ft.) (Min./inch) ?© r Feet 93.S Feet <br /> 300 z 4 <br /> VII. TANK Capa it Total #of Prefab. Site Fiber- plastic Exper <br /> in gallons Manufacturer's Name Concrete Con- Steel glass APP <br /> INFORMATION New Existin Gallons Tanks structed <br /> Tanks Tanks A 1_ ® ❑ ❑ ❑ El Eleptic Ta or Holding Tank w ❑ ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank(Siphon Chamber <br /> Vlll. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsi 'lity for installation of the onsite MP MPRSW No.: <br /> shown on usiessPhone Numached ber: <br /> Plumber's Name:(Print PI mber'ssignatu :( Stamps) <br /> ZZSZ2 iS �6� <br /> P umber' Address(Street city,State, ip Code): <br /> S (p vv <br /> IX. COUNTY/DEPARTMENT USE ONLY / <br /> $ (tar Permit FOC (Includes Groundwater ate s ue Issuing Age $(gnat r2`trio a ps) <br /> ❑Disapproved 1y 5efee) ��p/� l�1G <br /> &4pproved ❑owner Given Initial <br /> V Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASON FOR DISAPPROVAL: <br /> DISTRIBUTION: Original to County.One coPY To: Safety 6 Buildings Division,Owner,Plumber <br /> SBD-6398(R.11/97) <br />