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Ex P' Pte;/ FE?,rh_n- and Buildings Division <br /> A"Lonsin SANITARY PERMIT APPLICATION 201 E.Washington Ave. <br /> In accord with ILHR 83.05,Wis.Adm.Code P.O.Box 7969 <br /> Department of Commerce Madison,WI 53707-7969 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County <br /> than 81/2 x 11 inches in size. t4Ftjt:_n <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> 3 _36 yso <br /> The information you provide may be used by other government agency programs ❑Check if revision to previous application <br /> [Privacy Law,s. 15.04(1)(m)]. <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION <br /> Propert Owner Name Property Location /; <br /> ZSK�F1/4 1/4,S 23 T 9O ,N, R I& E(or& <br /> PropeOwner's Mailing Address Lot Number BIeeleAk ftb*r <br /> City,State Zip Code Phone Number Subdivlzl Name or CSM Number <br /> aT>< MN• ( (o5I)774-450 %t.• roIF,. SO <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ City Nearest Road <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms Z- ❑ Iowan OF �Kl�tib r�lS ff <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo 02D 432_S <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 online B,if applicable) <br /> A) 1. % New 2. ❑ Replacement 3_ ❑ Replacement of 4_ ❑ Reconnection of 5. ❑ Repair of an <br /> System System Tank Only Existing System Existing System <br /> ----------------------------------------------------------------------------------------------- <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 /> 11r" Bed 21 Mound 30 Specify Type 41 Holding Tank <br /> 12 N [3E] C]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 /> 30� ReqL �sq.ft.) Propos(sq.ft.) (Gal y/sq.ft.) (Min./inch)( �s S Elevation OG r`-� 7 Feet Feet <br /> Ca acct <br /> VII. FORMATION in gallons Total #of Manufacturer's Name Prefab. Con- Steel Site Fiber- Plastic Exper. <br /> New Existin Gallons Tanks Concrete structed glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank OO S00 Kf} 0 ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber I ❑ ❑ ❑ ❑ ❑ ❑ <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 tamps) MP/MPRSW No.: Business Phone Number: <br /> 41 c 14q)RV o pgj,,j5 + -1►f f55( (S- -q{S`C <br /> P mber's Ar dress(Street,City,Stat ,Zip Code) <br /> �'7?(o O w 3 S48 .3 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (includes Groundwater Date Issue Issuing A eWgna,,re(Ni S ps) <br /> *Approved ❑Owner Given Initial �15 Sur argeFee) <br /> Adverse Determination / <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.11/96) DISTRIBUTION: Original to County.One copy To: Safety&Buildings Division,Owner,Plumber <br />