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.� Safety anBuildings Division <br /> a <br /> SANITARY PERMIT APPLICATION Bureau of BuildingWaterSystem, <br /> In accord with ILHR 83.05,Wis.Adm.Code 201 E.Washington Ave. <br /> 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 g <br /> than 8 112 x 11 inches in size. G <br /> • See reverse side for instructions for completing this application State Sanitary Permit riumber <br /> The information you provide may be used by other government agency programsUr/ `�c /6 <br /> [Privacy Law,s. 1 5.04(1)(m)]. �` W J ElCheck if cf previous lication <br /> �f State Plan I.D. ber ) <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION (02 oc;0 , <br /> PropertOwner Name Property Location ' <br /> C �m +,a-S T N, R S E(or W <br /> Propert Owner's Mailing Address Lot Number Block Number <br /> City,State zip Code P one Number Subdi inion Name r er <br /> Ko E _ ( I2) VOL. <br /> II. T PE F BUILDING: (check one) ❑ State Owned ❑ Lily Nearest Road <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms �- ❑ Town <br /> Town OF- F}LKSO/J v, <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo IZ 4ZZ3 06 -560 <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 online B, if applicable) <br /> A) 1 ❑ New 5 2- p<Replacement 3. E] Replacementof 4. [:] Reconnection of 5- E] Repair of an <br /> ------ stem-y ---- -- System ------------- Tank-Only- -------------Existin9 <br /> System ExistingSystem <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)4 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 /> Req ed(sq.ft.) Proposed(sq. ft.) (Gals/da Min./inch) Elevation <br /> 3� <br /> VII. TANK Capacity e <br /> INFORMATION in gallons Total #of Manufacturer's Name Prefab. Site Fiber- Plastic Exper <br /> New Existin Gallons Tanks conuete Con steel glass App. <br /> Tanks Tanks structed <br /> Septic Tank or Holding Tank Z n - 1:10 <br /> Lift Pump Tank/Siphon Chamber E4 Q 0 ❑ 0 ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> [,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name:(Print) Plumber's Signature: o mps) MP/MPRSWNo.: BusinessPhoneNumber: <br /> r � <br /> P tuber's Address(Street,.City' <br /> St ,Zip Code): <br /> 0 v S Lill. <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> E]Disapproved Sanitary Permit Fee (indudesGroundwater ate s ue Issuin en Sign ture(N t ps) <br /> A <br /> roved �c./�jurcharge Fee)PP ❑Owner Given Initial �!' <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SOD-6398(R.05/94) DISTRIBUTION: Original to County,One copy To: Safety 8 Buildings Dimaon,Owner,Plumber <br />