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Safe and Buildings Division <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> "-Airco sin P O Box 7 I <br /> Department of Commerce In accord with ILHR 83.05,Wis.Adm.Code Madison,WI 53707-7302 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County <br /> than 8112 x 11 inches in size. <br /> • See reverse side for instructions for completing this application Sta a SSaanitary PermitNumber <br /> Personal information you provide may be used for secondary purposes ❑Check i�revision to previous application <br /> IPrivacy Law,s. 15.04(1)(m)]. State Plan I.D.Num er <br /> I. APPLICATION INFORMATION- PLEASE PRINT ALL INF RMATION <br /> Property Owner Name Property Location <br /> Uhl n„,.L-C 5Uj va 4w v4,S 2+ T N, R g E(or W <br /> Property Ownei s Mailing Address Lot Number VIM <br /> Cit ,State O Zi ode ' Phone Number Subdivision Name or CSM Number <br /> 49AW 1 ( t5>(o89-73 <br /> II. PEBUILDING: (check one) ❑ State Owned ill Nearest Road <br /> village �( <br /> Public 1 or 2 Famil Dwellin -No.of bedrooms 3 Town OF C)OD RS to <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 042 e07-55Z-3 ©Z �b <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. [:1 Reconnection of 5. E] Repair of an <br /> S stem --------System -------------Tank Only-------------- Existing System ----_----Existing Srstem <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 /> 11 M Seepage 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 15. Perc. Rate 6. System Elev. 7. Final Grade <br /> Required q.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> 1 Feet (o. O Feet <br /> VII. TANK Capacity Site <br /> in gallons Total #of Manufacturer's Name Prefab. Con_ Steel Fiber- plastic Exper. <br /> INFORMATION New Existin Gallons Tanks Concrete structed glass APP. <br /> Tank Tanks <br /> Septic Tank or Holding Tank -- 19 <br /> 11 <br /> Lift Pump Tank/Siphon Chamber ❑ El ❑ 1-1 ❑ 13 <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plu er's Name:(Print) Plumber Is Signature: No ps) MP/MPRSW No.: B j�gh <br /> Num er:_ <br /> ii <br /> Ic <br /> Plu ber'sAddress6ttreet,City,St ZipCode): <br /> ,2 , <br /> — �� s W <br /> IX. COUNTY/ DEPARTMEW USE ONLY <br /> ❑Disapproved Sanitary Permit a (indudesGroundwater ate ssue Issuing Agent ignatu A(Nomps <br /> ) <br /> Surcharge ree) ap <br /> Approved ❑Owner Given Initial �� 8 <br /> Adverse Determination (�I <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.11/97) DISTRIBUTION: Original to County.One copy To: Safety&Buildings Division,Owner,Plumber <br />