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cv <br /> Safety and Buildings Division <br /> WAsconsin SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> In accord with ILHR 83.05,Wis.Adm.Code P 0 Box 7 <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. T74RrjgTr <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> X5353 <br /> Personal information you provide may be used for secondary purposes ❑Check it revision to previous application <br /> (Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> 1. APPLICATION INFORMATION- PLEASE PRINT ALL INF RMATION <br /> PropertOwner Name Property Location <br /> (r CiADK15 1/4 1/4,S T ,N, R ((p E(or) <br /> Property Owner' Mai lingAddress Lot Number Block Number <br /> -1 E ST- N. <br /> Cit State Zip Code Phone Number Subdivision Name or CSM Number <br /> 2e ((y12)5 2 1 AIIJSo1 / <br /> II. BUILDING: (check one) ❑ State Owned ❑ City Nearest Road <br /> Public Eff 1 or 2 Family Dwelling-No.of bedrooms �' O VII ge <br /> Towan OF 0AkL1%I`t41S1 A W C.'t', <br /> 111. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo 020- 00'90-03- Z00 <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. '�j New 2.�Replacement 3_ ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> System ystem - ---System --- --- _- Tank Only --- --- - Existing S---------------stem Existin S stem <br /> -------g-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,W 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 /> _5O Required(sq.ft.) Pro osed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> 0Z �.O .7 �" 2, Feet 16�o Feet <br /> VII. TANK Capacity <br /> INFORMATION in gallons Total #of Manufacturer's Name Prefab. ion Fiber- plastic Exper <br /> New Existin Gallons Tanks concrete strutted Steel glass App <br /> Tanks Tanks <br /> Septic Tank or Holding Tank 5-0 1 ❑ 01 0 1 1:1 El <br /> Lift Pump Tank/Siphon Chamber •SGb Soo Q EJ El E El <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> PP <br /> ber's Name:(Print) r` Plumbers Signature`.( Stamps) MP/MPRSW No.: Business Phone Number:Zill5 <br /> ileMiev <br /> PI mber'ssAddress(Street,Ci y,State,Zip Code <br /> L <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Pe it Fee (�ndudesGroundwater ate ssue Issuing Age nat a(N ps) <br /> Approved []Owner Given Initial � (�(� Surcharge Fee) — <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS F ISAPPROVAL: <br /> SBD-6398(R.11/97) DISTRIBUTION: Original to County.One copy To: Safety Is Buildings Division,Owner,Plumber <br />