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cty)yp. <br /> Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION Bureau of Building Water System! <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 I <br /> than 8 112 x 11 inches in size. ���� o <br /> • See reverse side for instructions for completing this application State Sanitary <br /> ��PPerrr�m}}it yufn�r <br /> If <br /> The information you provide may be used by other government agency programs El CO2 f,t}}it/ v7lDn ,previous application 0 <br /> [Privacy Law,s. 15.04(1)(m)I. State Plan I.D.Number ( `) <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION 0/1) <br /> Property Owner N me Property Location <br /> , Z f S vnJ e/4 /UC'� 1/4,S T y O,N, R E(or)© <br /> Property Owner's Mailing Address / Lot Number Block Number, <br /> © 9m� c C/a d D G, L <br /> C. y,State Zip Code Phone Number Subdivision Name oK-SMiJumber <br /> A/r C/-,=e-k 1sv (71.!r all-3y 7o54- L -5 <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned Elit�VilNearest Road <br /> El Public 1 or 2 FamilyDwelling- No.of bedrooms ❑ Town of .� Co</ L 4fSecS �'- <br /> Iu. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo 0 ;2,P 2f 7s" o <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- gReplacement 3_ ❑ Replacement of 4_ ❑ Reconnection of 5. ❑ Repair of an <br /> System --- System ------------- Tank Only Existing System stem Existin9 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 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 /> Y.s� 6 5'O is Y .L 9-s3 Feet 9j, Feet <br /> Capant <br /> VII. TANK in allo s Total #of Prefab. Site Fiber- Exper. <br /> INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel Plastic p <br /> New Exist' structed glass App <br /> Tanks Tanks <br /> Septic Tank or Holding Tank 000 /eve ❑ ❑ El El 0 <br /> Lift Pump Tank/Siphon Chamber I 1 ❑ ❑ ❑ <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 Mumber'sSignature:(N Stamps) MP/MPRSW No.: Business Phone Number: <br /> Ae� 4f <br /> Plumber's Address(Street,City,State,7tip Code): <br /> c> — S—/� 5' <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit ee (Includes Groundwater ate lssuQ Issuing Agen ign ture mps <br /> Approved ❑Owner Given Initial 5� urcnarge Fee) V7 <br /> /� <br /> v Adverse Determination G/C <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.05/94) DISTRIBUTION: Original to County,One copy To: Safety&Buildings Division,Owner,Plumber <br />