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/ <br /> , ..Y , Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION Bureau Building <br /> lnr5ystem shngtoAvev <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 Count <br /> than 8 112 x 11 inches in size. <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> I s <br /> The information you provide may be used by other government agency programs E]Check it revision to rev ous 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 NaProperty Location <br /> 1/4 1/4,S,_,;? T ,N, R /S E(or <br /> Property Owner's Mailing Adi6ress , . Lot Number Block Number <br /> City,State Zip Code Phone Number S r CSM Number <br /> E �N /ylN. 5' " (G/z>u ,S 93 a Z d� i!1 OVf • �; <br /> II. PE F B ILDING: (check one) ❑ State Owned ❑ ity Nearest Road <br /> ❑ Village T�G�s <br /> Public 1 or 2 FamilyDwelling- No.of bedrooms Town OF <br /> III. BUILDING USE: (if buildingtype is public,check all thatapply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo / a <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. [a New 2. ❑ 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 CASeepage 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 /> Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> �_n I 6 t,y8, x 6 /q�73 Feet 97. 2 Feet <br /> Capacity <br /> VII. TANK in Ca gallons Total #Of Prefab. Site Fiber- Plastic Exper <br /> New Existingstrutted <br /> INFORMATION Gallons Tanks Manufacturer's Name Concrete con- steel glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank dee, El R <br /> Lift Pump Tank/Siphon Chamber El ❑ El El I ❑ ❑ <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'sSignature:(NoStamps) MP/MPRSWNo-: Business Phone Number. <br /> Plumber's Address(Street,City,State,Zip Code): <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> [:]Disapproved Sanitary Permit Fee li"dudes Groundwater ate Issue ssui gent Sig re(No Stamps) <br /> Surcharge Fee) <br /> pproved ❑Owner Given Initial I —j .� <br /> Adverse Determination -�v <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> S80-6398(R.05/94) DISTRIBUTION: Original to County,One copy To: Safety 8 Buildings Divrion.Owner,Plumber <br />