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boc, ocog3 W1S5 :5;0 Fund �' (may ; <br /> Safety and Buildings Division <br /> irCC�: 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 �] <br /> than 81/2 x 11 inches in size. E?U&mt �j <br /> • See reverse side for instructions for completing this application State Sanitary PermitNumber <br /> A_5� 9/1 <br /> The information you provide may be used by other government agency programs ❑Check it revision to previous application <br /> In.ivacy Law.:. t s.oa(s)(m)1- State Plan 1 D.Nglt)beis ,y .rf 90 <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property O!Aner Name Property Location <br /> ,�34014114 SATJJ k 1/4 1/4,5 <br /> ocatiins T 39 ,N, R IC E(Or) <br /> Property Owner's mailing Address Lot Number Block Number <br /> Z57141,9 • - 14 <br /> L— <br /> Cit- State Zi d Phone Num er Subdivision Name or CSM Number <br /> SlR�nl W) • ,) .,,, MOUIJD ad <br /> II. TYPE F BUILDING: (check one) ❑ State Owned ❑ ity NeareVst^RoIad , / <br /> Public 1 or 2 FamilyDwelling- No.of bedrooms Z ❑NeTown fes•►�W <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo ©/P <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 /> 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 I*Wound 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.) (GalsVda /sq. ft.) (Min./inch) _ Elevation <br /> 300 2SD 7ro 1 O►. OS Feet .3 Feet <br /> Capacity VII. INFORMATION in gallons Total #Of Manufacturers Name Prefab Con- Steel Fiber- Plastic Exper <br /> New Existing Gallons Tanks Concrete strutted glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank 75D �7tv u I ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber 0 ❑ ❑ I ❑ I ❑ Ij <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) Plumbers Signature(N amps) MP/MPRSW No.: Business Phone Number: <br /> l�riat¢A or �s3yz` <br /> Plu t <br /> tier's Address(Stre ,C�ty, ate,Zi Code): WI • <br /> IX. COUNTY/ DEPARTMENT E ONLY <br /> Disapproved <br /> Sanitary Permit Fee (I"`i°dee crovndwater sue IssuingA a Signa re <br /> �proved �yrchargefee) <br /> p ❑Owner Given /r 10 <br /> Adverse Determination ((// <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.05N4) DISTRIBUTION: Original to Counly.One ropy To: Safety&Buildings Dvision,Owner,Plumber <br />