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Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION Bureau Building Water Systems <br /> V�L'�•'• 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 StateSanitary Permit Number 0-6 <br /> ()q� 7 <br /> The information you provide may be used by other government agency programs ❑Check it revs i to previous apulication <br /> IPrivacy Laws. 15.04(1)(m)l. State Plan l.D Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Name P;o BertLocation5 �� T ,N, R 5 E(or W <br /> IqU <br /> Week F be <br /> Property Owner'Mailin Addr ss Lot Number <br /> �w NW <br /> City,State Zip Code Phone Number Subdivisl ame or CSM Number <br /> N 303 L� <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ ate Nearest Road �p� <br /> ❑ To age �ArYfON �• �� 1-l/- <br /> Public 1 or 2 FamilyDwelling- No. of bedrooms �_ Town of �J�! <br /> Parcel Tax Number(s) <br /> ill. BUILDING USE: (If building type is public,check all that apply) i <br /> 1 ❑ Apartment/Condo <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdo r Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 E] Restau ant/Bar/Dining <br /> 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Servic 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. ❑ Replacementof 4. ❑ Reconnectio of 5. ❑ Repair of an <br /> System System ------------- Tank-Only-------------- Exi--iQ yst m -___E -----System <br /> -------------------------- ---- <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 k 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 . System Elev. 7. Final Grade <br /> Requ red(sq. ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> Soo 2 :7 O Feet 96. 9-Feet <br /> VII. TANK Capacity ice <br /> in gallons Total #of Manufacturer's Name Prefab. on_ Steel Fiber- PlastickExperINFORMATION New Existin Gallons Tanks concrete sir cted gals pp <br /> Tanks Tanks <br /> Sep tic Tank or Holding Tank p[7� �� F ❑D 71 1:1 1 El F0 ❑ <br /> I lft Pump Tank/Siphon Chamber ❑ <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:(Pant) Plumber's signature: o amps) MP/MPRSW No.: Business Phone Number. <br /> �IS'7 <br /> Plumber's Address(Street,City,State,ZipC wl: q 16b� W f/LOq? <br /> 71 <br /> 35 <br /> IX. COUNTY/ DEPARTMENT USE ONLY w W J (O IJ <br /> Disapproved Sanitar ermit Fee 0,,dA sGmundwater ate Issue Iss ingA tSi atur 0Stamps) <br /> ❑ pp Surcharge Feel <br /> Approved ❑Owner Given Initial 15t,( , <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> I <br /> Stu 396(w.05194) )MRIRUTION. on,,alto Cowl ,OnewPy To: SafetyB&ulJln9a Olm.mn,Owneq Plu Ger <br />