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Safety ar, <br /> SANITARY PERMIT APPLICATION Bureau oflb <br /> In accord with ILHR 83 05,Wis.Adm.Code 201 E W 7969 <br /> � P.O.Box 7969 <br /> Madison,Wl 53-1,,, <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. �12.klerc <br /> • See reverse side for instructions for completing this application State Sanita y Pt mgeer V <br /> The information you provide may be used by other government agency programs ❑cneck it revision to previouspplicanon <br /> [Privacy Law,s. 15.04(1)(m)J_ State Plan I.D.Nu�]ber <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Nam Property Location <br /> 1/4 1/4,S --S�7_T N, R E(or)W <br /> Property Owner's Mailing Address Lot Nu er Block Number <br /> 340 – 30 +k ST. 114. ;?— <br /> ..It ,State1,) Md Zi Code Ph ne Number Subdivision Name or CSM Number <br /> Yr ( ) <br /> II. TYPE OF BUI DING: (check one) ❑ State Owned ❑ city Nearest Road <br /> ❑ Village �` ,� p <br /> Public 1 or 2 FamilywellingD -No. of bedrooms 3 Town of IV :5r_ <br /> III. BUILDING USE: (if buildingtype ispublic,check allthatapply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo = _ ZZ5 0L 700 <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_ E] Replacement 3. [:] Replacement of 4. E] Reconnection of 5. E] 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 Meepage Bed 21 ❑Mound 30❑Specify Type 41 ❑Holding Tank <br /> 1 2❑"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) (� / E evation <br /> 3 ,7 -I,3. W Feet 2,Feet <br /> Capacity <br /> VII FORMATION in gallons Total #of Manufacturer's Name Prefab. Con- Steel Site Fiber- Exper <br /> Gallons Tanks Concrete glass Plastic App <br /> New Existin strutted <br /> Tanksl Tanks <br /> Septic Tank or Holding Tank ❑ ❑ ❑ ❑ ❑ <br /> I.Fft 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 Sta s) MP/MPRSW No.: Business Phone Number: <br /> I tits 2z S I S- 467 <br /> - <br /> Plu ber's Address(Street,City,State,Zip Code). - <br /> `2-"1 0o vJ Wi wt . _5*S95 <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> E]Disapproved Sanitary Permit Fee (Includes6roundwater Date ssue Issuing AgentSgnatu (No to s) <br /> Approved Surcharge Fee) <br /> pp ❑Owner Given Initial 156 V /6) ? <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SHD-6398(R.05/94) DISTRIBUTION. original to Cm.,.t ,One ropy To Safely 8 Builainge Divi--ion,Owner,Plumber <br />