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��i'F�lige Safety and Buildings Division <br /> �• nn SANITARY PERMIT APPLICATION Bureau of Building Water Systems <br /> In accord with E.Washington Ave <br /> ILHR 83A5,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 J <br /> than 8 vi x 11 inches in size. a2/o / O <br /> See reverse side for instructions for completing this application State Sanitary P rmit Number / <br /> The information you provide may be used by other government agency programs 11 Q0� <br /> IPrivacy,Law,s. 1 5.04(1)(m)). ❑Cher;k i revision o previous application <br /> State Plan I Nu ber �- <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Name Property Location ^- <br /> 1/4 1/4,S $ T N, R �`F E(or) <br /> [Toperod <br /> Owner's Mailing Addr s Lot Numbergtock �4 FEL 4- CIRCf_6 N,ty,State Zip Code Phone Number Subdivision Name or CSM Number <br /> STILLI,J i'ER fJ, SSOSZ (412 )¢30-02 <br /> II. TYPE F BUILDING: (check one) ❑ State Owned ❑ city Nearest Road <br /> Public 1 or 2 Family Dwelling-No. of bedrooms �— o viI age Seo O <br /> Town OF �- Zj <br /> III. BUILDING USE: (IfbuiIcingtypeispublic,checkallthatapply) arcelTaxNumber(s) p <br /> 1 ❑ Apartment/Condo On 410$ OI 1Z.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 New System 2 ❑ Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5. ❑ Repair of an <br /> y_ System _ Tank Only --- -- - Existing System Existing System <br /> -- ------------- --------------- ----------------9-Y---- <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 rAseepage 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 6. System Elev. 7. Final Grade <br /> DO Req 'red(sq.ft.) Prop ed ft.) (Gals/day/sq. ft.) (Min./inch) / Elevation <br /> VII. TANK Capacity <br /> (�P • s �� fO - Feet .5 Feet <br /> INFORMATION in gallons Total #of Prefab. Site Fiber- Exper <br /> New Existin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App. <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank VV <br /> El ❑ El ElLift Pump Tank/Siphon Chamber 5DO ❑ ❑ ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT F—I <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name:(Print) tuber's Signature:(N tamps) MP/MPRSW No : Business Phone Number: <br /> der -9� rob7o <br /> P mber'sAddress(Street,city,State,Lip de): 1 <br /> / ,7/ Ssf <br /> IX.'COUNTY/DEPARTMENT U E ONLY <br /> ❑Disapproved Sanitary Permit FgQe (InludesGroundwater ;A71 <br /> Issuin <br /> rOVed / urchargeree) �A9entsig atur Stamps) <br /> P ❑Owner Given Initial �L /Jt /) <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.05/94) DISTRIBUTION: Original to County,One(upy To: Safety 8 Buildings Divi ion,owner,Plumber <br />