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Safety and Buildings Division <br /> `V SANITARY PERMIT APPLICATION 201 E.Washington Ave. <br /> �staonsin 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 Court <br /> than 8112 x11 inches in size. <br /> • See reverse side for instructions for completing this application State Sanitary <br /> Pe3Per( immt Number '/F�� <br /> The information you provide may be used by other government agency programs ❑Check I> sion to-previous application <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Numbe,� _ <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION I <br /> Property Owner Name /�,P rope Location <br /> O �t /_4,j L51 .1/a rd 1/4,S /0 T,;3<7 N, R% E(ort <br /> Property Owner's Mailing Acrdress Lot Number Block Number <br /> J <br /> City,State Zip Code Phone Number S ame o tuber <br /> Al'tje o/ ''A �:, _i 5.:,yam (6/2) 3r-0/ ,� 70 <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ City Nearest Road <br /> ❑ Village �J <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms a Town OF /1 U5 Cc, �� <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo Oa 3110 5 ac) <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, C' New 2_ ❑ Replacement 3. ❑ Replacementof 4. ❑ Reconnectionof 5. ❑ Repair of an <br /> System _ -_-_-- _ _ -__System Tank Only Existing System Existing System <br /> __S <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 gSeepage Trench 22❑In-Ground Pressure 42[:]Pit Privy <br /> 13 E]Seepage Pit <br /> p C ptitr Z 43❑Vault Privy <br /> 14❑System-In-Fill <br /> VI. ABSORPTION SYSTEM INFORMATION: <br /> 1. Gallons Per Day 2. Absorp.Area3. Absorp.Area 4. Loading Rate 5. Perc. Rate 6. System Elev. Final Grade <br /> Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) q _ El7.evation <br /> Feet 9 ,>Feet <br /> Ca act Site <br /> VII. INFORMATION in gallons Total #of Manufacturer's Name Prefab- Con- steel Fiber- Exper <br /> Gallons Tanks Concrete glass Plastic App <br /> New Existingstrutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank 5�t°O SQG) a ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ 1 ❑ ❑ ❑ <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:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> Plumber's Ar dress(Street,City,State,Zip Code): <br /> o X S' -5.r/'e_-"..; !r./ 3 7'p— <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sa itaryPermitFee (includes Groundwater ate ssue Issuin Age tSignature Trips <br /> pproved I ❑Owner Given Initial / Surcharge Fee) <br /> Adverse Determination ` 75- CLO 3 /G Q <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: - <br /> SBD-6398(R.1lM6) DISTRIBUTION: Original to County.One copy To: Safety&Buildings Division,Owner,Plumber <br /> L <br />