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Safety and Buildings Division <br /> �tGa.ii i SANITARY PERMIT APPLICATION Bureau ofBuMirigWatersystemS <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. 4_ o� <br /> • See reverse side for instructions for completing this application State Sanitary Permit Numer 1({l <br /> The information you provide may be used by other governmentagency programs ❑Check it revision to previous <br /> on <br /> (Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION 1�-- <br /> Property,Owner Nam Property Location <br /> �JAI Ke n W (x,14 SUJA 5W1/4,S T �j g ,N, R <br /> Property Owner's Mailing Address Lot Number Block Number <br /> Q <br /> City,Stater Zip Code Phone Number Subdivision Name or CSM Number <br /> k W ri ,5 O 1(7/4'7 - <br /> II. TYPE OF BUILDINIU: (check one) ❑ State Owned ❑ City QNea�rest:Ro]ad <br /> ❑ Village � 1 K Ra <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms %Town of t <br /> 111. BUILDING USE: (if buildingtype ispublic,check allthatapply) Parcel Tax Number(s) <br /> E] el <br /> 1 Apartment/Condo C/,?— c S-o.)_ S-00 <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- ❑ New 2. tg Replacement 1 ❑ Replacement of 4. ❑ 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 ❑Seepage Bed 21 KIVIound 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 16. System Elev. 7. Final Grade <br /> YRequir (sq. ft.) Proposed sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> SQ 33 I , 1100, 3) Feet eet <br /> Capacity VII. TANK in gallo s Total #of Prefab site Fiber- plastic Exper. <br /> INFORMATION Gallons Tanks Manufacturer's Name concrete con- Steel glass App <br /> New Existin strutted <br /> Tanks Tanks <br /> e tic Tank r Holding Tank )( f o0o^ (/ ❑ El El <br /> LrftPump Tank SlphonChamber X �N <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 Plu ber's Si natur :( Stamps) MP/MPRSW No.: Business Phone Number: <br /> �S �� Y ZLSZZ`( 7/ S� SO&CO-860k <br /> Plumber's Address(street,City,State,Zi C de): n` S_Y <br /> cLo <br /> IX. COUNTY/ DEPARTMENT USE ONLY tSignppp <br /> El Sanitary Permit Fee (ndudeserovndwaler ate Issue sluing Agture tamps) <br /> proved ❑Owner Given Initial 12,00ot <br /> Su" I - <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> S90-63911(8.05/94) DISTRIBUTION: Original to County,One ropy To. Safely&Ruildings nivuion,Owner,Plumber <br />