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{7N CoSt,�PII�'�.FcISCANNu'O <br /> Saf2yand=ion <br /> �t■�.ir■ SANITARY PERMIT APPLICATION Bureau of 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 G p <br /> than 81/2 x 11 inches in size. ej e"l-l 'e- W l � 3Q <br /> • See reverse side for instructions for completing this application State Sanitary Permit Nu <br /> m r� nt// <br /> The information you provide may be used by other government agency programs Check it revision <br /> to previous application <br /> [Privacy Law,s. 15.04(1)(m)] StatePlan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Name / Property Location C- ,� <br /> c5, -, - L �. b r y^ ! -1/4:5 C- 1/4,S / T ,N, R i_5 E(orci <br /> Property 0 er's Mailing A ress Lot Number Block Number <br /> City, tate Y Zip Code Phone Number Subdivision Name or CSM Number <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ City Nearest Road / <br /> Public 1 or 2 Family Dwelling-No.of bedrooms 5 Town OF TACAwti /0 A-. �rJ <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) ^� <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. ❑ 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 ®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 Rate5. Perc. Rate 6. System Elev. 17. Final Grade <br /> Required(sq. ft.) Proposed (sq.ft.) (Gals/day/sq. ft.) (Min./inch) c� Elevation <br /> y Feet <br /> Capacity <br /> VII. INFORMATION in gallons Total #of Manufacturer's Name Prefab- ion Fiber- Plastic Exper <br /> New ExistingGallons Tanks Concrete Steel glass App. <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank QO.' CT e Z ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ 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's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> Plumber./'s�Address(Street,City,State,Zip Code): <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (Includes Groundwater ate Iss7ed, jIssurrAyGr6ntStcwratur7 N tamps) <br /> ,fpproved ❑Owner Given Initial �Q urcharge Fee) <br /> Adverse Determination oL� <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(8.05/94) DISTRIBUTION: Orioinal to Count..One conv To: Safety 88uildinm Division.Owner.Plumber <br />