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OP omp <br /> Safety and Buildings Division <br /> �i'L�tNi€L SANITARY PERMIT APPLICATION Rureau ofRuildingWater 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. <br /> • See reverse side for instructions for completing this application states mtar,Per itNumber69 <br /> The information you provide may be used b other government agency programs � / 7 <br /> y p y y q g y p 9 Check it rev cion 1 previous apPlicalion <br /> (Privacy Laws. 15.04(1)(m)I. State Plan 1.D Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION —oZ <br /> Pro erty Owner Name r Property Location <br /> /� Kr 5S/cJ2/' 1/4 1/4,S /Y T d ,N, R /64E (or) 11l_�' <br /> Property Owner's Mailing Ad res Lot Number lock Number <br /> 70 7' eI*k-e_ �a�h <br /> City,Statet�.,[ Zip Code Phone N `�- <br /> umber --�-•^n Name or CCSNA Number <br /> nlUei'Gfo✓ 't r `r /r/. ( ) !/0 / a Zp <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ ity Nearest Road <br /> � ❑ Village ® d I <br /> Public 1 or 2 FamilyDwelling1- No. of bedrooms c� Town OF C' Ik V. <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo L <br /> / <br /> ��/_��� _ ��'�lO <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restau ant/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. ❑ Reconnectio 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 /> NonPressurizedDistribution Pressurized Distribution Experimental Other <br /> 11 ❑Seepage Bed 21 ❑Mound 30❑Specify Type 41 04} olding 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 PerDay 2 Absorp.Area 3. Absorp.Area 4. Loading Rate S. Perc. Rate 6 System Elev. 7. Final Grade <br /> Required (sq. ft.) Proposed (sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> c� e o — — Feet s Feet <br /> Capacity <br /> VII. INFORMATION in gallons Total #Of Manufacturer's Name Prefab. <br /> New Existin GdllOnS TanksConcrete stru ted Steel glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank &00 s&06S L J�- 11 ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ 11 ❑ ❑ 1 ❑ I ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown n the attached plans. <br /> Plumber's Name:(Print) Plumber's Signature:(No Stamps) MPRSW No : Business Phone Number <br /> Plum ber's Address(Street,City.State,Zip Code): <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> El Disapproved Sanitary Permit Fee (l.nivdes Groundwater ate ssue ssu gent Sign re(No Stamps) <br /> Approved ❑ narge ieel <br /> Owner Determination al Y7� � <br /> Adverse Determination <br /> X. C NDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: <br /> SHn'b39u IH.051-34) 0191RIHUTION- Original to C^unly,One<nPY T^ Saie1yd8... ng�Dler.ion,Owner,Vlum r <br />