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�. nnmoj <br /> SI" and BuIIding Division <br /> �.t■■.�n 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 <br /> than 8 1/2 x 11 inches in size. &,c 0_1 � W�J<� <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number,iii <br /> The information you provide may be used by other government agency programs El Check if rl,v�on o revi�apPhCation <br /> [Privacy Law,s. 15.04(1)(m))_ State Plan I.D.JVµgtber <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION �(,x�� <br /> Prncerty Owner Name Property Location <br /> r')6tj (),4101CI1/4 1/4,S T C) ,N, R )S -E(or <br /> Property Owner's Mailing Address Lot Numb Block Number <br /> 96 &5*1 <br /> City,State Zip Code Phone Number Subdivi ion Name or CSM Number <br /> Q.9tiJUQt 1 57V �� (71F ),?S -77 ADD, r ✓ V. ° fee C <br /> d. <br /> 11. TYPE F UILDING: (check one) E] State Owned ❑ City Nearest Roa -.2C,65� <br /> lage 4- <br /> Public 1 or 2 Family Dwelling-No.of bedrooms ; Town OF 9aXS0/J -1k <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo 75~ <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 __ stem - Tank Only Existing System Existing System <br /> B) Sanitary Permit was previously issued. Permit Number 3 Date Issued -o��j-�� <br /> V. TYPE OF YSTEM: (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) r Elevation tr <br /> C l ) � e � t — ��- Feet y p Feet <br /> Ca aut <br /> VII. TANK in Lap <br /> Total #of Prefab. Site Faber- Exper <br /> INFORMATION g Gallons Tanks Manufacturer's Name Concrete Con- steel Plastic p <br /> New Existin strutted glass App. <br /> Tanks Tanks ,�j7-� <br /> Septic Tank or Holding Tank A /� 4cl ❑ ❑ ❑ LI ❑ <br /> Lift Pump Tank/Siphon Chamber r l <br /> VIII. RESPONSIBILITY STATEMENT CdCCt-�i� !on/JfoN <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name:(Print) Plumber' No m 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 Fe (Includes Groundwater ate su IlssuingA t ignatu ( m s) <br /> Approved ❑Owner Given Initial ` � Surcharge Fee) /75- , <br /> Adverse Determination ( � � t 4 <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.05/94) DISTRIBUTION: Original to County,One copy To: Safety&Ruitaings Division,Owner,Plumber <br />