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Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> *6consin In accord with ILHR 83.05,Wis.Adm.Code P O Box 7302 <br /> Department of Commerce Madison,WI 53707-7302 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County1 <br /> than 8 1/2 x 11 inches in size. <br /> • See reverse side for instructions for completing this applicationate Sanitary P/eimit ober <br /> Personal information you provide may be used for secondary purposes C]Check it r vis(onto pTevidus application <br /> (Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION <br /> Propert Owner Name Property Location <br /> ICK LaE�LER t/a E 1/a,S T N,R �& E(or) <br /> PropertOwner's Mailing Address Lot Number BI k Number <br /> IAS (,5th Rd N W 2- — (o7�d cR�S <br /> ' ,State zip Code P one Number Subdivision Name or CSM Number <br /> Qw 11'fog MIJ• 55117— ( Iz. )$D 44-13 <br /> 11. TYPE OF BUILDING: (check one) ❑ State Owned 0 '.t� 7reecr_. <br /> earest Road <br /> Vd age w n <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms Z Town OF V <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo 020 x{31 t 05 900 <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. 'D4 Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5_ ❑ Repair of an <br /> __System --------System ------------- Tank Only_-___-_______ Existing 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 /> 11Seepage Bed 21 ❑Mound 30 E]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 5.Perc. Rate 6. System Elev. 7. Final Grade <br /> Required(s ft.) Propped(sq.ft.) (Gals/day/sq.ft.) (Min./inch) p � Elevation <br /> 300 I I Wor5 �—� Feet 'IG- Feet <br /> VII. TANK <br /> Capacity <br /> INFORMATION in gallons Total <br /> lllltons Tanks Manufacturer's Name Conc este con Steel glass Plastic Aper. <br /> New Existing strutted <br /> Tanks Tanks I <br /> Septic Tank or Holding Tank <br /> Lift Pump Tank/Siphon Chamber El 1:1 11 [1 0 E] <br /> Vlll. 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 mps) MP/MPRSW No.: YBusiness Phone Number: <br /> P mber's Address(Street,City,St e,Zip Code) <br /> 7-77 : )1 � �1• � �� <br /> ' 60 w 3k W <br /> IX. COUNTY/DEPARTME T USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (Includes Groundwater fja—te-7sssu—e Issuin A nt Signatur ( o mps) <br /> Approved ❑Owner Given Initial Surcharge Fee) V19 6/ <br /> ?9 <br /> Adverse Determination Q <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.11/97) DISTRIBUTION: Original to County.One copy To: Safety&Buildings Division,Owner,Plumber <br />