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Safety and Buildings ADivision <br /> 201 W.Washington Avenue <br /> 5�On5%n SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83 05,Wis.Adm.Code P 0 Box 7 <br /> 302 <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 81rz x 71 inches in size. ,iiQACAJtr1' � <br /> • See reverse side for instructions for completing this application State Sanitary P/eerr/mi�ttNNumbe <br /> Personal information you provide may be used for secondary purposes 3 I `� <br /> [Privacy Law,s. 15.04(1)(m)]. ❑Check it rewsio to previous application <br /> I. APPLICATION INFORMATION- PLEASE PRINT ALL INFORMATION State Plan I.D.Numb � <br /> Pr°pe'�o ner Name Property Location <br /> Td/ 1C'1 d F- 114J-w 1/4,S orb T 37 ,N, R/8 E(or;111�9) <br /> Property Owner's Mailingddress Lot Number Block Number <br /> '/S d d -'h (20r S <br /> City,Stater Zip Code Phone Number Subdivision Name or CS Number <br /> ( �s ) ye c' v�� 1/4 <br /> II. TYPE OF-BUILDING: (check one) ❑ State Owned ❑ It �Kd / , NearesstRoad <br /> 1� ❑ Village M� e_dJ ,G <br /> Public 1 or 2 FamilyDwelling- No.of bedrooms own of <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 E Apartment/Condo 1 Q <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 ---------ystem ------------- 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 /> 12Xeepage Trench /+ 22❑In-Ground Pressure 42❑Pit Privy <br /> 13[]Seepage Pit ��✓T. l/7.c E°7`a;c j! C7�yo je:f�� 43❑Vault Privy <br /> 14❑System-In-Fill jZ k�� f3 . j.7M/, IL7( ' <br /> VI. ABSORPTION SYSTEM INFORMATION:- <br /> 1- <br /> NFORMATION: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) Elevatio <br /> .3 D d 3& 2�, � 8 83• Feet 8b. Feet <br /> Gapactt <br /> VII. TANK in gallons Total #of Prefab. Site Fiber- plastic Exper <br /> INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel lass A <br /> New Existin strutted g pp <br /> Tanks Tanks <br /> Septic Tank or Holding Tank x (SO q)y.) El 11 n El El <br /> LIR Pump Tank/Siphon Chamber ❑ ❑ El I ❑ Q El <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sews e system shown on the attached plans. <br /> umber's Name:(Print) Plumber's Signature:(No Stamps) MP 2S <br /> -3 No.: I Business Phone Number: <br /> C)42L4 dw SNS LZ,7-e-7L /S-47Z- 9Y (, <br /> P umbe 's Address(Street,City,State,Zip Code): <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> �f ❑Disapproved Sanitary Permit Fee (lndudes Groundwater ate ssue Issuin A ntsig ature mps) <br /> [� roved urcnarge ree) <br /> ��// pp ❑Owner Given Initial 7 SGt 7- <br /> c�j <br /> Adverse Determination `� <br /> X. CONDITIONS OF APPROVAL/REASONS FORDISAPPROVAL: <br /> SBD-6398 IRA 1197) DISTRIBUTION: Original to County.One copy To: Safety&Buildings Division,Owner,plumber <br />