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t (f� ety and Buildings Division <br /> VisSANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> Consin 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 County <br /> than 8 1/2 x 11 inches in size. .Bu!'A <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 5 <br /> ❑Check if revision to previous application <br /> [Privacy Law,s. 15.04(1)(m))_ State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEA E PRINT ALL INF RMATION V� <br /> Prop �Ow er Na Property Location N, R�� E(O <br /> c�.4 - >06 r a,o �,/gs� ,/a,s T 38 <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 79;Ra 7-0t4iar` T-- <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> Ill. PE BUILDING: (check one) E] State Owned ityy e do= s Nearest Road <br /> Public 1 or 2 FamilyDwelling- No.of bedrooms "2 E] Towan OF 1&7�y <br /> 111. BUILDINGUSE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo 30 5;7-717 0 Yav <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. Ig New 2. ❑ 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 R5eepage 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 5.Perc. Rate 6. System Elev. 7. Final Grade <br /> Required(sq. ft.) Proposed(sq.ft.) (Gals/da A ft.) (Min./inch) Elevation <br /> —3 G'O9 .fB �S. 9 Feet 79, 3 Feet <br /> Capacity <br /> VII. TANK in gallons Total #Of Prefab. Site Fiber- Exper. <br /> INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> New Existin structed <br /> Tanks TanksI <br /> �r <br /> Septic Tank or Holding Tank 7:5-0 7-5--o E ❑ ❑ ❑ I ❑ ❑ <br /> Lift Pump Tank/Siphon Chambers--to 6 So Z) `" ® ❑ ❑ ❑ ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumbers Name:(Print) Plumber's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> /It.) <br /> Plumber's Address(Street,City,St9te, ip Code): <br /> IX. COUNTY/ DEPARTMENT USE ONLY it <br /> Ilnc udes Groundwater ate IssuedIssuin tZSgnDisapproved Sanitary Perm t FeP' �jrge Fee) g , <br /> �groved ❑Owner Given Initial / � —��4V <br /> V Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.11197) DISTRIBUTION: Original to County.One copy To: Safety&Buildings Division,Owner,Plumber <br />