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fety and Buildings Division <br /> SANITARY PERMIT APPLICATI ureau 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 Count <br /> than 8 vi x 11 inches in size. ,� e old-)g X <br /> • See reverse side for instructions for completing this application State Sanitary Permit Numberfr <br /> The information you provide may be used by other government agency programs 1;Z 09U/`3 <br /> ❑check it revision to previous application <br /> IPnvacyLaw,s. 15.04(1)(m)J_ StatePlanl.D Numb <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION s Q <br /> Property Owner Name <br /> perty Location <br /> 1/4 /4,S <br /> TN, R/6 E (or�/v o <br /> ro ertOwner's Mailing Address Lot Number Block Number <br /> jo <br /> City,State Zip Code Phone Number SeWw4tet4-NameorCSMNUmber <br /> Wed 7�e� L.J-.F- e,, jo / 2 C <br /> II. TYPE OF BU DING: (check one) ❑ State Owned ❑ city Nearest Ro d <br /> ❑ Public or 2 FamilywellingD - No. of bedrooms Town OF /77e�/0cJnJ �i4 v. <br /> !II. BUILDIN U E: (if building type is public,check all that apply) Parcel TaxNumber(s) <br /> o1(6 - 3� -;L (:)- G9 - ©® <br /> 1 ❑ Apartment/Condo <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 KReplacement 3. ❑ Replacement of q ❑ 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 ❑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 /> Required (sq- ft. Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> OAl.? D . �����Feet 9a. Feet <br /> VII. TANK Capacity <br /> INFORMATION in gallons Total #of Manufacturer's Name Prefab. Site Con- Fiber- Plastic Exper <br /> New Existin Gallons Tanks Concrete strutted Steel glass App <br /> Tanks Tanks <br /> Septic Tank or Holding Tank ,.6-0 1,;!5-0 R 0 n <br /> Lift Pump Tank/Siphon Chamber, '00 &,.-j 4) ® ❑ ❑ El ❑ ❑ <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:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> Plumber's Address(Street,City,Stale,Zip Code): _ <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fe (indudes&oundwater Date Iss ed issuing Age gnatur <br /> s) <br /> Approved E]Owner Given Initial Surcharge Fee) <br /> V Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD6398(R.05194) DISTRIBUTION-. original to county,One copy To: Sufety B Ruil,Ings niv.ion,Owner,Plumber <br />