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vrii4ai: <br /> SANITARY PERMIT APPLICATION Safety andBuildi9Water15 stems <br /> Bureau of Buildin y <br /> In accord with ILHR 83.05,Wis.Adm.Code 201 E.Washington Ave.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 Sta eSaanitary Permit Number <br /> ` ( <br /> The information you provide may be used by other government agency programs _ "08 1 <br /> [Privacy Law,s. 1 5.04(1)(m)]. ❑Check if revision to previous application <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION- PLEASE PRINT ALL INFORMATION <br /> PropertOwner Name Property Location <br /> R S[1/4 1/4,S 29 Tgo I <br /> N, R E(or)( <br /> Property Own is Mailing Address Lot Number Block Number <br /> SDS Rn <br /> City,St to ZI Code Phone N ber Subdivision Name or CSM Number <br /> sr n WI. s� 93 (TS > 6• _ <br /> II. TYPE OF BU LDING: (check one) ❑ State Owned It Nearest Road <br /> Public 1 or 2 Family Dwelling- No. of bedrooms z' ❑ Town OF� CJC�,Of l Cc <br /> III. BUILDING USE: (If building type is public,check all thatapply) Parcel Tax pNumber(s) <br /> 1 E] Apartment/Condo ©1- {0so 01 *0 <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 System 2 eplacement 3. Replacement of q ❑ Reconnection of 5. E] Repair of an <br /> y _� E]---- -- O <br /> - Tank Only Existing System ExistingSystem <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 ❑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.) (MinAnch) Elevation <br /> 30 <br /> 0 o -500 b• Feet 3 Feet <br /> VII. TANK Capacity <br /> INFORMATION in gallons Total #of Manufacturer's Name Prefab. Site Fiber- Expp. <br /> New ExistingGallons Tanks Concrete Con- Steel glass Plastic App <br /> Tanks Tanks structed <br /> Tir 1:1 <br /> Septic Tank or Holding Tank GfEl 1:1Lift Pump Tank/Siphon Chamber El E] El Ej El ElVIII. 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' Signature: No mps) MP/MPRSW No.: Business Phone Number: <br /> Ic �R (S- /Sl <br /> Plumber's Address(Street,City,Sta e,Zip Code): <br /> W1. 8 3 <br /> IX. COUNTY/DEPAR E T USE ONLY <br /> ❑Disapproved Sanitary Per it Fee (includes Groundwater W15 <br /> sue Issuing Agen ign re amps) <br /> proved ❑Owner Given Initial , � r`na`ge Fee) Cj/Adverse Determination 70c") 6io <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: r I / <br /> SBD-6398(R.05/94) DISTRIBUTION: Original to County.One copy To: Safety 8 Buildings DW,sion,Owner,Plumber <br />