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oy� c <br /> pMo <br /> Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION Bureau Building Water Systems <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 8 112 x 11 inches in size. ,Qel/`A-11&_ <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> The information you provide may be used b other overnmenta enc programs ��.l�a <br /> Y P Y Y 9 agency P 9 ❑Check i revision to previous application <br /> [Privacy Law,s. 15.04(1)(m)I. State Plan I.D. umlie f� XJ <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION ///7// <br /> Property Owner N me Property Location <br /> Xe.:; & T*-;,V o U-5 &-1/4 ��1/4,S 2 / T,7e ,N, RIZ E(or <br /> Property Owner's Mailing Address Lot Number Block Number <br /> A6/ L�/.9 /�aeoq R� - <br /> CityyState Zip Code Phone Number Subdivision Name or CSM Number <br /> 55li^e^_i ctd S-Y9 ( 1301-s'33s <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ City Nearest Road <br /> ❑ Village <br /> Public 1 or 2 Family Dwelling- No. of bedrooms Town OF rates 4e C",4ve, <br /> Ill. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo 06 � rya C C? <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. EXReplacement 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 ❑Seepage Bed 21 j6h/lound 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 /> 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) Elevation <br /> ,--T e 0 a�.Sca a7 1. ~— �d r: Feet/d,2- Feet <br /> 1- Gallons Pe 77 <br /> Capact <br /> VII. INFORMATION in gallons Total #of Manufacturer's Name Prefab. Con-Site Fiber- plastic Exper <br /> New Existin Gallons Tanks Concrete Steel glass ADD <br /> New <br /> Tanksl Tanks <br /> Septic Tank or Holding Tank 7-6-c) )SO L✓ �_/� El EJ El 1:1 El <br /> Lift Pump Tank/Siphon Chamber oe) FOc) 9 ❑ ❑ ❑ ❑ ❑ <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/MPRSW No.: Business Phone Number: <br /> Plumber's Address(Street,City,State,Zip Code): <br /> O S'/�,z e-.f/ 5- <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee 1(indudes croundwdter ate Issue Issuing Agent Si ature <br /> pproved ❑Owner Given Initial OV `�)surcharge Fee) / b <br /> Adverse Determination (J �� Z� / <br /> X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: <br /> SBD 6398(R.05/94) DISTRIBUTION: Original m(nur,ty,One copy To: Safety 8 Buildings Divcion,Owner,PlumtKr <br />