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OnCnrr ( , <br /> Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION Bureau of Building Water System <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 12 x 11 inches in size. �41 3C iL o- 9 <br /> • See reverse side for instructions for completing this application State Sanitary Permit Nymber <br /> The information you provide may be used by other government agency programs E]Checkiii rev�on to sap applicalion <br /> (Privacy Law,s. 15.04(1)(m)). State Plan I.D.Numbe rr <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION �/V/ <br /> Property Owner Name Property Location <br /> ILK 1/4 1/4,S L T 3 V,N, R� S—E (or)Wc, <br /> Property Owner's Mailing Ad ress Lvk#tromber Block Number <br /> 1 <br /> s9 �tL. AV .l G, L, <br /> Cit ,State Zip Code Phone Number 5 division Name or CSM Number <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ Cit Nearest Road <br /> Public 1 or 2 Family Dwelling- No.of bedrooms Towa9 OF���� �- <br /> ❑ l t� r Pn;,LJ t <br /> II. BUILDING USE: (if buildingtype ispublic,check allthatapply) Parcel TaxNumber(s) <br /> 1 F-1 Apartment/Condo J,2 <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_ M New 2. ® Replacement 3- Q Replacement of 4- Q Reconnection of 5_ Q Repair of an <br /> System System Tank Only Existing System Existing System <br /> ----------------------------------------------------------------------------------------------- <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 ❑Mound 30❑Specify Type 41 ❑Holding Tank <br /> 12❑Seepage Trench 22 Q 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 /> Re wired (sq. ft.) Pro osed (sq-ft.) (Gals/day/sq.ft.) (Min./inch) c� El�rvation <br /> YOFeeFeet <br /> TANK Capacity <br /> VII. INFORMATION in gallons Total #of Manufacturer's Name Prefab. Sit Fiber- Plastic Exper <br /> New Existin Gallons Tanks Concrete Steel glass App <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank lej:7)) ❑ ❑ ❑ <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:(Prl ) - - J Plumber's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> Plumber's Address(Street,City,State,Zip Code): <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> E]Disapprove Sanitary Permit (includes chargeonndwater ate ssNe� ssuingA gnat <br /> A roved %��✓ sun<nar9e ree> !//� <br /> P [-]Owner Given Initial <br /> Adverse Determination l <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.05194) DISTRIBUTION: Original to enunly,One copy To: Safety 8 Buildings Divulon,owner,Plumber <br />