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A 1,11110"i <br /> Safety and Buildings Division <br /> �:LaR SANITARY PERMIT APPLICATION Bureau of Budding Water Systems <br /> In accord with ILHR 83 05,Wis.Adm.Code 201 B Washington Ave. <br /> P.O.Boz 7969 <br /> Madison,WI 53707-7969 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less county / r/ <br /> than 8 1/2 x 11 inches in size. altjjzhft <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 � 6 / <br /> e ` <br /> lPrivacy Law,s. 15.04(1)(m)I_ ❑Check it revision to previous application r � <br /> State Plan I.D.Number V <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property caner Name Property Location <br /> v4 1/4,S T 40 ,N, R 1f E(or <br /> Property Owner's MailingBlo <br /> Adores Lot Number ck Number <br /> 3 I6 r1EA001� 1Zi=Eid t�.(. <br /> City,State Zip CodePppone N mber Subdi inion Name or CSM Number <br /> I• PoIZ)1R1- Ofo40pp . <br /> II. TYPE F B I DING: (check one) ❑ State Owned it� Nearest Road <br /> Public 1 or 2 FamilyDwelling- No. of bedrooms 3 ❑ Vi l age .SC•lir M wl Kew v4- <br /> Town OF <br /> Ill• BUILDINGUSE: (If building type is public,check all that apply) Parcel Tax <br /> }Nuumber(s) 22 /^ <br /> 1 E] Apartment/Condo Dg0 �`30,9, �� 1 <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 /> S ❑ 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. j4 New 2_ ❑ Replacement 3. ❑ Replacement of 4- E] Reconnection 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 /> Non-Pressurized Distribution Pressurized Distribution Experimental Other <br /> 11 DO 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. Pert. Rate 6. System Elev. 7. Final Grade <br /> Required(sq. ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min ins Elevat�iQn <br /> 3 6N4 91.9 Feet �•`� Feet <br /> VII. TANK Capacity <br /> INFORMATION in gallons Total #of Manufacturer's Name Prefab. Site Fiber_ Ex er <br /> New ExistingGallons Tanks Concrete Con- Steel glass Plastic App - <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank 1000 -- I 0 �� ® El ElEl ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber Lj r-1 r-1 r-1 ❑ <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:(N tamps) MP/MPRSW No.: Business Phone Number. <br /> �Hr�xv s 26 7 S 866- /rl <br /> Plumber's Address(street,City,Sta ,Zip Code). <br /> 2 w 3s Esst&t AVII S 93 <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> �g.� ❑Disapproved Sanitary Permit F e ('noudes Groundwater ate IssuedIssuin �en/tS ign ur NO Stamps) <br /> rOVed ❑ Surcharge fee) ' <br /> i�SPP Owner Given Initial lll/NN/ <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SHO 6398(R.05/94) DISTRIBUTION: Original to County,One<.,Ta: Safety 8 Building>Divui4n,Owner,Rlumber <br />