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Safety and Buildings Division <br /> Visconsin SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> 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. 15 ( <br /> • See reverse side for instructions for completing this application State sanitary Permit <br /> Number <br /> Personal information you provide may be used for secondary purposes ❑Check it revisi�o gree s`appl©tio <br /> (Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> I. APPLICATION INFORMATION- PLEASE PRINT ALL INF RMATION <br /> Property caner Name ropert Location <br /> r+a� 1/4,S -7 T40 N,R L IC <br /> E(or W <br /> Property Owner' Mailing Ad ress Lot Number Block Number <br /> City,State Zip Code hone Number Subdivision Name or CSM Number <br /> t 6�)31s_ <br /> BUILDING: (check one) ❑ State Owned � ity IMO-11 01 <br /> Nearest Road <br /> ❑ Village Public lo r 2 Family Dwelling-No.of bedrooms 1— own of • 90- <br /> 111111. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Numberr((s)),,,,hh <br /> 1 [-] Apartment/Condo 012_ T�7 O2' 400 <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. Replacement 3. [:] Replacement of 4. C] Reconnection of S. Repair of an <br /> ____Syrstem __ 14flSystem- _ ------ Tank Only______________ ExistImSystem _____ ExistlnoSystem <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 E]Mound 30❑Specify Type 41 ❑Holding Tank <br /> 1 A3 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/day/sq.ft.) (Min./inch) p evation <br /> 3Bd 61 2. .� �� (i'•9 Feet o.9 Feet <br /> VIICa act. TANK Ingallons S Total #of Prefab. Site Fiber- Exper <br /> INFORMATION g Gallons Tanks Manufacturers Name concrete con- Steel glass Plastic App <br /> New Existingstructed <br /> Tanks Tanks <br /> Septic Tank or Holding Tank _L+5< El � ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber <br /> VIII. 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 amps) MP/�MP�RSW�`No.: B�u]s/iness Phone Number: <br /> t^ 1 �/ I`�_ <br /> Plu er's Address(Street,Cit , tate,Zip Code): <br /> 2. �0 <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved a itary Permit Fee (includes Groundwater ate Issued Issuing Agen 5 atur Sta ) <br /> pproved ❑Owner Given Initial 5 /HI/rte <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DIS PPROVAL: <br /> SBD-6398(R.11/97) DISTRIBUTION: Original to county,One copy To: Safety 8 Buildings Division,Owner,Plumber <br />