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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 count <br /> than 8 112 x 11 inches in size. 1 &4_vr <br /> • See reverse side for instructions for completing this application State Sanitary Permit Nu er <br /> The information you provide may be used b other government agency programs Ro��� - <br /> Y P Y Y 9 9 Y P 9 ❑C ec revlston to previous application <br /> ]Privacy Law,s. 15.04(1)(m)]. <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION $357 <br /> Property Owner Name Property Location L <br /> eon �►ecK 1/4 1/4,S la-T 40 N, R 14 W <br /> Property Owner's Mailing Address Lot Number Blo Number <br /> E 0 Au- Skr�r 4v' <br /> City, to Zip Code Phone Number Subdivi n Name or CSM Number <br /> AGoo L,� s3ti13 c > <br /> II. TYPE OF BUILDING: (check one) ❑ State Ownedit� Nearest Road <br /> Public 1 or 2 FamilyDwelling- No.of bedrooms 1 ❑ vil age <br /> own OF .SG+01'k <br /> III. BUILDING USE: (if buildingtype ispublic,check allthatapply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo 1 OL$'HI- IZ-oz-4510 <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. ZNew 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5_ ❑ 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❑ 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 12. 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 /> 1S0 I25 12-5 I,Z rlae 1, •S JObS Feet 104.2-Feet <br /> Capaut <br /> VII INFORMATION in allo s Total #of Manufacturer's Name Prefab. Con Steel fiber- Plastic Exper. <br /> New Existin Gallons Tanks Concrete strutted glass App. <br /> Tanks Tanks <br /> Septic Tank or R —T50 1 1 '25-0 ®® ❑ ❑ ❑ ❑ ❑ <br /> lift Pump Tank/%WAioo-E awrtrer 500 1 .Soo 9 ❑ ❑ ❑ ❑ ❑ <br /> VI11. RESPONSIBILITY STATEMENT <br /> I,the undersigne#"L*e responsi ' ity for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's`AWW& EX'tiAVA t r s ignatur .(No Stamps <br /> )lum 2! frW/MPRSW No.: Business Phone Number: <br /> 1•(tt ill: r a��1sr'19 <br /> Plumber's Address Code). <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit F (Includescroundwater Date Issued Issuing Agent ignature(N S ps) <br /> pproved ❑Owner Given Initial /1, t7V Sur`harge'ee) <br /> Adverse Determination 2W <br /> X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: <br /> SHE)6398(R.05/94) DISTRIBUTION: Original to County,One copy To: Svtety&9uildings Divoion,Owner,PlumWr <br />