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fu1 C <br /> Safety and Buildi�sion <br /> �`.■ •• SANITARY PERMITAPPLICA� Bureau aBuildingWaterSystem: <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 0 �� <br /> than 8 12 x 11 inches in size. `/� <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> 36/ 66L1 <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 ,n <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION ,k <br /> Prop rt Owner Name PropeLocation <br /> 1/4 1/4,S 2a- T 41 N, R L- E(or)® <br /> !C 0 <br /> Prop rty Owner's Mailing Address Lot Number Block Number <br /> City,Stat Zip Code Phone Number Subdivision Name or C M Number <br /> S >25ri-35bo u- <br /> c IN h14. <br /> II. TYPE F U DING: (check one) ❑ State Owned ❑ Cit Nearest Road <br /> Vil5lage c <br /> Public 1 or 2 FamilyDwelling- No.of bedrooms Town OF 1, jzlCl� - <br /> III. BUILDING USE: (if building type is public,check all that apply) Parcel TaxNumber(s) <br /> 032-.57.24 03 400 <br /> 1 ❑ Apartment/Condo <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. ❑ Reconnection of 5. ❑ Repair of an <br /> System System Tank Only -------------Existing System -- _ Existing System <br /> ------------------------------------------------ <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 (gSeepage 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. System Elev. 7. Final Grade <br /> Requ red(sq. ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) p, a EI vation <br /> ,7 — Ls• 1 Feet qj- Feet <br /> VII. TANK Capacity Site <br /> INFORMATION in gallons Gallons Ta of <br /> Manufacturer's Name Conc Prefab. <br /> con- Steel glass Plastic App- <br /> New Existin strutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank e-I Sno / ^ 2— � sKA IR rI ❑ El 1:111 <br /> Lift Pump Tank/Siphon Chamber 1�� S,I;',a� 1:1 El n ❑ El <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 St ps) MP/MPRSW No.: Business Phone Number: <br /> ,/7�7�rt�Qn P lis 54,76s. <br /> Plu ber's Address(Street,City,State,Zi Code): <br /> ? 0 v 5BST <br /> IX. COUNTY/ DEPARTMENT-USE ONLY <br /> ❑Disapproved Sanitary Permit Fee Surcharge Fee) late Issue Issuing Agent Signatur Stamps) <br /> V/ Surcharge Fee) / /� <br /> pproved El Owner Given Initial � 10�1v' <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/ REASONS FO SAPPROVAL: <br /> SHD-6398(R.05/94) DISTRIBUTION. Original to County.One(opy To: Safety a RuilJings Division,Owner,Plumber <br />