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Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> Lponsin 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. u - a 3 <br /> • See reverse side for instructions for completing this application . State sanitary Permit Number ly ) <br /> Personal information you provide may be used for secondary purposes5 3c)3,76 <br /> ❑Check it revision to previous application <br /> [Privacy Law,s. 15.04(1)(m)J_ State Plan I.D.Number <br /> I. APPLICATION INFORMATION- PLEASE PRINT ALL INF RMATI N Lu <br /> Prope Owner anie Property Location <br /> O1/4 1/4,S 2 1 T N, R (o E(or) <br /> Prope -0 rs M ilingL6ddress Lot Number r <br /> Cit ,St ZiP Code P one N ber Subdivision Name or CSM Number <br /> 55 MN- lm ( 2> q pm ✓ <br /> 11. F LDING: (check one) ❑ State Owned I ° vlage Nearest Road <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms Town OF <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo <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. ❑ Reconnection of 5_ ❑ Repair of an <br /> __- ------System ------------- Tank Only Existing System ExistingSystem <br /> ------------9-Y------------------ -�---- <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 /> 1 1*eepage 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. Pert. Rate 6. System Elev. 7. Final Grade <br /> Req fired(sq.ft.) Pro osed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) evation <br /> 450 13 $ . 7 93•d Feet 1160.0 Feet <br /> VII. TANK Capacity <br /> in gallons Total #of Prefab. Site Fiber- Ex er. <br /> INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel Plastic p <br /> New Existin strutted 91ass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank 10001 -^ 1 1000 1 51<AV4 10 ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber I 1 ❑ ❑ ❑ ❑ ❑ ❑ <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) Plu er's Signature:( o ps) MP/MPRSW No.: Business Phone Number: <br /> P m tier's Address(Street,City,Sta e,Zip Code): J S. �AQ3 <br /> 2.`7O w W <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (Includes Surcharge <br /> water Fat, ssue Issuing A en ignat re mps) <br /> Vl,Aroved Surcharge Fee)PP ❑Owner Given Initial 1�6 UCJ 3 <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.11/97) DISTRIBUTION: Original to County,one copy To: Safety 8 Buildings Division,Owner,Plumber <br />