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Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION Bureau of Building Water Systems <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 rQ �,y <br /> than 812 x 11 inches in size. V <br /> • See reverse side for instructions for completing this application St to Sanitary Permit <br /> tNNumber <br /> The information you provide may be used by other government agency programs ElGAefck if revlsiDn to pre�us application <br /> [Privacy Law,s- 15-04(1)(m)1. State Plan I.D.N ber <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION I S 77.ao 3a17 <br /> Prope y Own r Name Property Location <br /> 1/4 1/4,S T N, R IG E(or W <br /> Prop6 Owner's aim Address Lot Number <br /> p d * ST. 2 <br /> Ct ,State Zi ode Phone Number Subdivision Name or CSM Number <br /> 0 1 ® b c - C-SM VOL. IS' P 17- <br /> 11. <br /> zII. TYPE OF BUILDING: (check one) ❑ State OwnedIty Nearest Road <br /> p village <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms Town OF uJ d <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo DIS Q <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 2/"Replacement 3. ❑ Replacement of q. E] Reconnection of 5. E] 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)7 Mound 30❑Specify Type 41 ❑Holding Tank <br /> 12❑Seepage Trench ❑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(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Mi ./inch) Elevation <br /> 30© <br /> 19,.508, Feetlot.8a Feet <br /> Capacity <br /> VII FORMATION in g llo s Total #of Manufacturer's Name Prefab Site Con- Steel Fiber- Plastic Exper. <br /> New Existing <br /> Gallons Tanks Concrete strutted glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber 1+ rNTJ VV IL ❑ ❑ I ❑ 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 Nam :(Print) Plumber's Signature: 0mps) MP/MPRSW No.: Business Phone Number: <br /> s I:f ,d 3 7� 18 6- l5'7 <br /> P tuber's Address(Street,City19 ,S ate,Zip Code): <br /> Q 35 1 6j35W 3 <br /> IX. COUNTY/ DEPARTMENT USE ONLYI. <br /> ❑Disapproved Sanitary Permit Fee (includes Groundwater ate ssue Issuing Agen ignat a(No S ps <br /> pproved ❑ �J surcharge fee) <br /> Owner Given Initial 0 <br /> Adverse Determination Ct'1d�� 1612-191 <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.05,34) DISTRIBUTION: Original to County.One ropy To: Safely 8 Buildings Division,Owner,Plumber <br />