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Safetyand Buildings 1) <br /> XUYXXPF4mXP <br /> �;a.; W vision <br /> SANITARY PERMIT APPLICATION Bureau of Building Water System: <br /> 201 E.Washington Ave. <br /> In accord with ILHR 83.05,W is.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. <br /> • See reverse side for instructions for completing this application State Sanitary Permit Numbe <br /> The information you provide may be used by other government agency programs ❑Check if revision to previous application <br /> (Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Name Property Location <br /> G a t o ,t.) &d1/4 1/4,S o2,3 T ,N, R /$ E(orXD <br /> Property Owner's Mailing Address / Lot Number Block Number <br /> 0.28 ' PF G'arJ N rl!r <br /> City,StateZip Code Phone Number Subdivision Name or CSM Number <br /> wszu c o.�a/g -�L, ©09 (YY7)S;�6 x Y/ <br /> II. TYPE F BUILDING: (check one) ❑ State Owned ;' El 't Nearest Road <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms' vllya <br /> a <br /> ( Town OF �4G'\ P <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo ©/ �II22 2 o v <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. I4 Replacement 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 /> 11Seepage Bed 21 ❑Mound 30 E]Specify Type 41 E]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 /> Required(sq. ft-) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) q Elevation <br /> t? W 9, 9 0 _-� - &< 9 /�' Feet 9�. Feet <br /> TANK Capacity <br /> VII INFORMATION in Ballo S Total #Of Manufacturers Name Prefab. Con Steel Fiber- plastic Exper Existing Gallons Tanks concrete structed glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank m D �*� �' _� /4 © ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ <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 Sig/nature:(No Stamps) MP/MPRSW No: Business Phone Number: <br /> ✓��� /I Y��lal L✓?uE_- � yam-- �� �� �%g'- ��2 �� <br /> Plum/beer's Address(Street,City,State,Zip Code): <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (IndOdesr;roundwate( ate ssue Issuing g t Sign ure(No Stamps) <br /> proved E)Owner Given Initial I�—� Su hargeFee) (_a <br /> Adverse Determination C —y� <br /> X. CONDITIONS/OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.05/94) DISTRIBUTION: Original to County.One copy To: Safety 6 Buildings Divr ion,Owner,Plumber <br />