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Visconsin <br /> Safety and Buildings Division <br /> 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 Cou y <br /> than 8 112 x 11 inches in size. a1c3 o�%p <br /> 0 See reverse side for instructions for completing this applicatijvI ,j-r� � unitary Permit Nu ber <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)]. State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF MATION <br /> Propertywne ame Propert Location <br /> Vwlle £ / S AC 1/4 1/4,S �� T at A— ,N, R� E(or)W <br /> Propert O net"s Mailing Addr ss 2� / Lot Number _1 Block Number <br /> lT7 /1 37 <br /> Cit tate Zip d Phone Num er r ( f <br /> ✓e 7a (7,S-)3<jy 777 /v. S <br /> II. ' BUILDING: (check one) ❑ State Owned L] Lt Nearest Road J <br /> ❑ Village ]g q ��.�` of led <br /> — <br /> 111. <br /> 1 or 2 FamilyDwellingo <br /> - No.of bedroms � w <br /> Ton of O) <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo Oz-43/G--o,-3_tl D <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/Mote[ 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) 1New 2. E] Replacement 3. [:] Replacement of 4. [:] Reconnection of 5_ E] 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 Seepage 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/day/sq.ft.) (Min./inch) Elevation <br /> ©Q 5 /a80 � S 75-- 7 FeetS, Feet <br /> Capact <br /> VII. FORMATION in allons Total #of Manufacturer's Name Prefab Site Con- Steel Fiber- Plastic Exper <br /> New Existin Gallons Tanks Concrete strutted glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank 1/a 0 at ElEl ❑ ❑ E] <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:(PrinA Plumber's Signature:Wo Stamps) MP/MPRSW No.: Business Phone Number: <br /> u�t.<� �/ 9,- 7�ae6' <br /> Plu•�' er's Ac dress(Street,City,State,Zip Code): <br /> kUd?X <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee lindudesGroundwater Date Issued Issuing entSignature(No Stamps) <br /> A roved <br /> NDIT <br /> surcharge Fee) <br /> Owner al Co <br /> Adverse Determination 4 ISb. <br /> IONS /Q lh�LCnC/ <br /> � <br /> OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.11196) DISTRIBUTION: Original to County.One copy To:Safety&Buildings Division,Owner,Plumber <br />