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Safety and Buildings Division <br /> • •••'• Bureau of Building Water System <br /> r.��r>,r. SANITARY PERMIT APPLICATION <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 1/2 x 11 inches in size. <br /> • See reverse side for instructions for completing this application Sr <br /> am-ytaLr ermit Number <br /> J lam? <br /> The information you provide may be used by other government agency programs El Check it revis un to previous application <br /> IPrivacy Law,s. 15.04(1)(m) . <br /> State Plan LD. umber <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Name Property Location <br /> py` SWI/4 5E1/4,S .75 T ,N, Rjy E(or <br /> Property Owner's Mailing Address Lot Number Block Number <br /> PL <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> ,.:F/::1`00 A_ Y 0 (7l5) <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned Elify Nearest Road <br /> ❑ Village <br /> [j Public 1 or 2 FamilyDwelling- No.of bedrooms Town of 11 <br /> II. BUILDING USE: (if buildingtypeispubhc,checkallthatapply) Parcel TaxNumbber(s) a� <br /> 1 ❑ Apartment/Condo <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoo Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining <br /> 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service tation/Car Wash <br /> S ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: s ecify <br /> IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) <br /> A) 1. 0C New 2_ ❑ Replacement 3_ ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> System System Tank Only Existing Syste Existing System <br /> B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued <br /> V. TYPE OF SYSTEM: (Check only one) <br /> Nom Pressurized Distribution Pressurized Distribution Experimental Other <br /> 11 XSeepage Bed 21 ❑Mound 30❑Specify Type 41 ❑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. ystem Elev. 7. Final Grade <br /> Required (sq. ft.) Proposed sq.ft.) (Gals/day/sq. ft-) (Min./inch) Elevation <br /> 4150 Z13 <br /> C V. 9 Feet , Feet <br /> Capact <br /> VII. INFORMATION in gallons Total #of Manufacturer's Name Prefab Con Fiber- Plastic Exper <br /> New Existin Gallons Tanks Concrete steel glass App. <br /> struct d <br /> Tanks Tanks <br /> Septic Tank or Holding Tank JAe>o Ovg . witris" K E ❑ ❑ ❑ ❑ <br /> Lilt 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 Signature:(No Stamps) MP/WPfKW.No.: B siness Phone Number: <br /> `' M h 7370 r,6 lyll 6- a <br /> Plumber's Address(Street,City,State,Zip Code): <br /> W W 75' <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee Bndudes Groundwater Date Issued Issuing g tSignat ( o5ta ps) <br /> 4A roved Surchageree) <br /> pp ❑Owner Given Initial I C' f* <br /> Adverse Determination `�-..LJ — <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> thD-ti398(h.OV94) 01MRIBUTION'. Ori,miiho(oum,,one ropy To: S.Jery B RuiLlings Divc.lon,Owner,Plumber <br />