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D�ACZ17_f�, <br /> Safety and Buildings Division <br /> ��� ■��+ �j��{.�. Bureau of Building Water Systems <br /> ��■a.r■n SANITARYPERMITA IC '���'�77� 201 E.Washington Ave <br /> In accord with ILHR 83.05,Wis-Adm.Code �S�ANNEDP.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 /> �� Q �� <br /> than 8 112 x 11 inches in size. <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> The information you provide may be used by other government agency programs ❑Check it revision to previous application <br /> [Privacy Law,s- 15-04(1)(m)]. State Plan I.D.Num <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Namer4, Property Location <br /> Prnpid 6, 1/4 1/4,S T �� ,N, R Jk(or)V <br /> Property Owner's Mailing Address Lot Number1 lock Number <br /> 15 Lc_ � 7 <br /> Cit ,State Zip Code I Phone Number Sub'division_Name or CSM ber <br /> 11 <br /> II. TYPEOF BUILDING: (check one) ❑ State Owned ❑ City jNeare§PRoad <br /> ❑ Village <br /> Public M 1 or2lFamily Dwelling- No. of bedrooms _12L rg Town OF <br /> III. BUILDING USE: (if buildingtype is public,check all that apply) Parcel TaxNumber(si`)++ <br /> 1 ❑ Apartment/Condo `i' 15 1 2-- I> 0® <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- nsfl New 2. E] Replacement 3. E] Replacementof 4_ [:] Reconnection of 5. E] Repair of an <br /> ____ System __System ___________ TankOnly---------------Existing System __ __ExistingSystem <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 IV Seepage Bed 16 X 3& 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,(s�.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) i Elevation <br /> L450 I`tom I LP Ll 8 IS Feet 2 Feet <br /> Capacity VII INFORMATION in gallons Total #of Manufacturer's Name Prefab. Con_ Steel Fiber- Plastic Exper <br /> New Existin Gallons Tanks Concrete strutted glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank — 1000 ❑ ❑ ❑ El <br /> Lift 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 Signaure:(No 5 s) P Business Phone Number: <br /> Plumber's Ad drs(Street,W5,State,Zip Code): <br /> pd)lIr I , F <br /> IX COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (1ndudes Groundwater atessued Issuing Agent Signature(N St ps) <br /> proved E]Owner Given Initial 1.5� Od Surchargelee) 9111 h7 <br /> Adverse Determination Gam y <br /> X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: <br /> SND-6396(R.05/94) DISTRIBUTION Original to Gmr,ly,One copy To: Safety 8 Ruiiding%Dim>wn,Owner,Plumber <br />