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Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION Bureau of Building Water Systems <br /> 201 E.Washington Ave. <br /> In accord with ILHR 83.05,Wis.Adm.Code P.O.Box 7969 <br /> Madison,WI 53707-7969 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County <br /> than 8 112 x 11 inches in size. 9 yy11P <br /> • See reverse side for instructions for completing this application state sanitary Permit Number The information you provide may be used b other government agency programs y p y y 9 9 y p 9 C]Check it revision to pliviol application `, <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number'' II �IIJ <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION O Zf� `7 <br /> pert Own Na ropertly'Location <br /> N <br /> e1/4 W 1/4,5 11 T ,N, R �� €(e W <br /> Property Owner's ail gAddress Lot Number Block Number <br /> �O 00 i l �St` �v Le.-e_. <br /> City,State Zip Code P one N n r Subdivision Name or CS Numb <br /> A4 I'. Ss 3 c is>�}`� S�o3 Csy✓1 Ur P, 3o ov4-, -d <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned 'To�tlw(an <br /> Nearest Road <br /> El 3 ge ''// p4Public 1 or 2 Famil Dwellin -No.of bedrooms of )'1't��2 �F-e. 'tel IT t T t [�.- s <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) 7 <br /> 1 ❑ Apartment/Condo 3q Is <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. ;g Replacement 3_ ❑ Replacement of 4. E] Reconnection of 5_ ❑ Repair of an <br /> System System --- - 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 olding 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 /> Required (sq. ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> 'So Feet Feet <br /> Ca act <br /> VII. INFORMATION in gallons Total #of Manufacturer's Name Prefab- Con- steel Site Fiber- Plastic Exper. <br /> New Existin Gallons Tanks Concrete structed glass App. <br /> Tanks Tanks <br /> Septic Tank Holdin ' (e Cavtcii ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsi ility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name: rl ) PI mber'sSigna re/ No Stamps) MP/MPRSWNo.: Business Phone Number: <br /> e LS t-er aasaa- C�-bo8' <br /> Plumber's Address(Street,Civ:State,Zip Co � r V <br /> I COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (includes GroundwaterF <br /> /3-Q�e Issue Iss -,g A ent SI n ture(No Stamps) <br /> A roved Surcharge Fee) ` <br /> pp ❑Owner Given Initial ' <br /> Adverse Determination 41b <br /> . 00 <br /> X. ONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.05/94) DISTRIBUTION: Original to County.One copy To: Safety&Buildings Division,Owner,plumber <br />