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C-4)ct ►AND <br /> Safety and Buildings Division <br /> i:.�oE Mrs SANITARY PERMIT APPLICATION Bureau BuildingWaterSystem <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 �Q <br /> than 8 12 x 11 inches in size. <br /> • See reverse side for instructions for completing this application State Sanitary Permit N mb r <br /> ?0ob <br /> The information you provide may be used by other government agency programs E]Check II revision to previous application J <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number - l� <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION I A119- �F <br /> Prope Owner Name Property Location <br /> 1/4 1/4,S 7- T qO ,N, R <br /> Property Owner's Mailing Address Lot Num''qqe Bleek-d. ber 1 <br /> -211 <br /> L <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> SER 80%16 M.5. MN,I 55076 ( t2 ) - % <br /> 11. TYPE OF BUILDING: (check one) ❑ State Owned ❑ City Nearest Road <br /> Village <br /> Public 1 or 2 Famil Dwelling- No-of bedrooms y Town OF �AKt-�1�D C1RC(E �D- <br /> 111. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo 020 4307- 03 100 <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. D<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 14 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 S. Perc. Rate 6. System Elev. 7. Final Grade <br /> Req fired(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) �t Elevation <br /> ' <br /> zoo zq 30 . 7 9"t•q Feet 7.4 Feet <br /> Capacit <br /> VII. FORMATION Con- Steel glass in allons Total #of Manufacturer's Name prefab plastic Aper. <br /> New Existin Gallons Tanks Concrete strutted Blass App. <br /> Tanks Tanks c <br /> Septic Tank or Holding Tank SW 1— �8 Jk AN4 ® ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ <br /> Vill. 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 Signa��turr (N tamps) MP/MPRSW No.: Business Phone Number: <br /> 1 G A o X1q lam" t f � 2& 5' st /6' 5* <br /> Plumber's Address(Street,City,Slate,ZipCode)-IF <br /> 760 w 5 WWSMEAL SgSTS <br /> IX. COUNTY/DEPARTMJENT USE ONLY <br /> rr1- ❑Disapproved Sanitary Permit FPS Includes Groundwater ate Issue Issuing Signa o t ps) <br /> �IFIIK'. roved (7(J Surcharge Fee) <br /> [Gv\pp [—]Owner Given Initial •i <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.05/94) DISTRIBUTION: Original to County.One copy To: Safety B Buildings Division,Owner,Plumber <br />