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� C:��D . <br /> Aff �^ Safety and Buildings Division <br /> 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 8 112 x 11 inches in size. B �,3! <br /> • See reverse side for instructions for completing this application State Sanitary <br /> Permit Number <br /> The information you provide may be used by other government agency programs ❑Cock it revision c�»�ious application <br /> [Privacy Law,s. 15.04(1)(m)). State Plan I.D.NumberXIA, `,r� <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION — <br /> Property Owner Name Property Location <br /> ,d A/ Sjj a 1/4 1/4,Sia, T �eo N, R/6 E(orcw) <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 5/0 --5- 0, ej d; 1 a <br /> City,State Zip Code Phone Number Subdivision Name or CSfvl-Number <br /> S clNer wF 5,V216/ I( »66-y.>67 -e �,frle5 ESfafe-- <br /> 11. TYPE OF BUILDING: (check one) ❑ State Ownedity Nearest Road <br /> lge <br /> E] Public 1 or 2 FamilyDwelling-No.of bedrooms ❑ Town OF 0,9L Z 41-1-J %)qs r. <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo 0.20 9aaar a.-.2 OD <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. r""01 2. ❑ Replacement 3. ❑ Replacement of 4_ F] Reconnection of 5_ ❑ Repair of an <br /> System System Tank Only Existing System Existing 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 D72. 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 /> el�,� . 6 9' 95`- Feet 97, Feet <br /> TANK Capacit <br /> VII• INFORMATION in allons Total #of Manufacturer's Name Prefab. Site Steel Fiber- Plastic Exper. <br /> New Existin Gallons Tanks Concrete Con-strutted glass App <br /> Tanks Tanks <br /> Septic Tank or Holding Tank ❑ ❑ ❑ ❑ ❑ <br /> Lrft 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 Stamps) MMP/MPRSW No.: Business Phone Number: <br /> Plumber's Address(Street,City,State,Zip Code): 100, <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (mdudeiGrouodwater W <br /> sue Issuing Agen Ignatu mps) <br /> roved s argeree) <br /> p ❑Owner Given Initial „` <br /> Adverse Determination Ll <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SND-6398(R.05/94) DISTRIBUTION: Original to County,One copy To: Safety 8 Buildings Division,Owner,Plumber <br />