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u� C-L <br /> S fety and Buildings Division <br /> �• •�� Bureau of Waters stem <br /> �.■inr.■. SANITARY PERMIT APPLICATION n y <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 12 x 11 inches in size. <br /> • See reverse side for instructions for completing this application State SanitaryPermit Number <br /> ' <br /> The information you provide may be used by other government agency programs [I Check it revisiprf rb prdGioSs application <br /> [Privacy Law,s. 15.04(1)(m)J_ State Plan I.D.Number , <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION ���0/ <br /> Prop y Owner Name Property Location <br /> R 1/4 1/4,S 13 T40 N, R 5 E(or)(W <br /> Propert wner's Mailing Address Lot u her Block Number <br /> 43 1 AwKIcN A�. s . �- qG <br /> Cit ,State Zi Code Phone Number Su ivision Name or CSM Number <br /> tS 5p5409 (4lz-)823-884a o V.V. <br /> II. TYPEOF BUILDING: (check one) ❑ State Owned ❑ Ity Nearest Road <br /> ❑ Village �,�'',` <br /> ❑ Public 1 or 2 FamilyDwelling- No.of bedrooms Z Town OFICiI$O �R. Aa <br /> HI. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo - 012. Q325—01 SOO <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 /> 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.Area3. 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 /> 3C 2q 432 .7 3.9 Feet qc.4 Feet <br /> Capacity <br /> VII. INFORMATION in allos Total #of Manufacturer's Name Prefab. Site Con- steel Fiber- Exper_ <br /> Gallons Tanks Concrete glass Plastic App <br /> New Existin strutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank VO 100 1 K ® ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ <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 mps) PRSW No.: Business Phone Number: <br /> IcdARO 0 Af u ,( MP/MZLI IS- &G- 4-157 <br /> PI mber's Address(Street,City,State Zip Code): <br /> 2-1 60 i4w14 3 613sTez W1. 9W3 <br /> IX. COUNTY/DEPARTMENT USE ONLY Al <br /> ❑DisapprovedSan/�Oitary Permit Fee (includes Groundwater ate Issue jIssumgA9eVntgna or tamps) <br /> ❑Approved F]Owner Given Initial / o Surcharge Fee) /I�q� <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL IA DISAPPROVAL: <br /> SND-6398(R.05/94) DISTRIBUTION: Original to Cnumy,One copy To: 5afety 8 Buildings Division,Owner,Plumber <br />