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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 63 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 12 x 11 inches in size. L P. q 1 <br /> sq <br /> • See reverse side for instructions for completing this application State Sanitary Permit <br /> N/('�'f�n b�J, <br /> The information you provide may be used by other government agency programs ❑Check it revD¢r WDu'�appllcatlort V I <br /> (Privacy Law,s. 15.04(1)(m)I. State Plan I.D.Number _ <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION N <br /> Property Owner Name Property Location <br /> S;'1014 T 1/4,S 31 T Jrl .N, R J `,E(or) <br /> Property Owner's Mailing Address Lot Number Block N er <br /> a A ✓ AIA <br /> Ci y,State Zip Code Phone Number Subdivision Name or CSM Number <br /> II. TYPE BUILDING: (check one) ❑ State Owned ❑ Cit T?� <br /> arest Road J <br /> ❑ Public 1 or 2 FamilyDwelling-No. of bedrooms �- IX o rowan OF R_ / <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo 0 o ?� —cZ/ a ov <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, it applicable) <br /> A) 1. ❑ New 2.jaReplacement 3. ❑ Replacement of 4, ❑ 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 ❑ Holding Tank <br /> 12 CRSeepage 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 (s ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) c� D Elevation <br /> ()� � O Z 7k 14 l 2' Feet Vis, 0 Feet <br /> TANK Capacity <br /> VII. INFORMATION in gallons Total #of Manufacturer's Name Prefab. Con- Steel Site Fiber- Plastic Exper_ <br /> New Existin Gallons Tanks concrete strutted glass App. <br /> Tanksl Tanks <br /> Septic Tank or Holding Tank lS 6 V a O ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber �6 0 ❑ ❑ ❑ ❑ ❑ <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 nat re:( 5 ps) MP/MPRSW No.: Business Phone Number: <br /> Plumb is Addr ss(Stree , ty, tate,Zip Code): <br /> HCl ��ct,c, / - <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (Intludes Groundwater Date Issue Issuin nt Si O Stamps) <br /> PAroved urchargelee) <br /> pp ❑Owner Given Initial <br /> Adverse Determination <br /> TIONS OF APPROVAL/ REASONS FORDISAPPROVAL: <br /> edn /I?l �s:leC� Tz- �D �f� /� ih o20 % <br /> DISTRIRUTION. Original to Cnunly,One copy To: S:dety 8 Buildings Division,Owner,Plurnter <br />