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&qca p <br /> Safety and Buildings Division <br /> . r SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> %s� onsin P O Box 7 I <br /> Departme,`,:f Commerce In accord with Comm 83.05,Wis.Adm.Code Madison,WI 53707-7302 <br /> • Attach co. tplete plans(to the county copy only)for the system,on paper not less County ayb <br /> than 8 tie x 11 inches in size. <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> E] 36a7o <br /> Personal information you provide may be used for secondary purposes Check if revision to previ us application <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION <br /> Pro ertOwner Name Property Location <br /> Ore x /1510 fi 5 Ila 11a,5 TXO N,R / � E(or W <br /> Pro a y0 er'sMailingAddress Lot Number Block Number <br /> ,a6,�-- 4/sr o. <br /> City,Stat Zip Code Phone Number Subdivision Name orvE-S"umber <br /> TYPE IL ING: (check one) ❑ State Owned � I. Nearest Road <br /> rl ❑ VII age /f�ius L <br /> Public or 2 FamilyDwelling- No.of bedrooms � own oF.S�'® coM <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) c� <br /> 1 ❑ Apartment/Condo O 4; 67 /�Q 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/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. gReplacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> Syfstem System _____ Tank Only _____________ ExistingSystem ________ 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-FillS"°r w"�el w� <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 /> Reoui�d(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./in(h) _ Elevatti' n <br /> J'o o S 15r, 7-15-- 1.0p — 1 /91 Feet C71 Feet <br /> VII. TANK Capacity Site <br /> in gallons Total #of Manufacturer's Name Prefab. Con_ Steel Fiber- plastic Exper- <br /> INFORMATION Pew <br /> ew Existing Gallons Tanks Concrete strutted glass App <br /> nks Tanks <br /> Septic Tank or Holding Tank h0 O/�W LgL <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. O mps) MP/MPRSW No.: Business Phone Number: <br /> GrJ.�I '� sy ol�1 - ��7G�/ �Y�-7��C <br /> Plumber's Address(Street,City,State,Zip Code): <br /> .6c.w SISI s%,^ <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved nitary Permit Fee "cludesGroundwater rate7s7suelssuinSu harge Fee) <br /> Approved ❑Owner Given Initial �®� <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> DISTRIBUTION: Original to County.One copy To: Safety&Buildings Division.Owner,plumber <br /> SBD-6398(R.4/99) <br />