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n ftynp r <br /> �'�g{ity and Buildings Division <br /> SANITARY PERMIT APPLICATION pc1�`8"ureau of Building Water Systems <br /> �SG 201 E.Washington Ave. <br /> In accord with[LHR 83.05,Wis.Adm.Code n``�� P.O.Box 7969 <br /> V Madison,WI 53707-7969 <br /> • Attach complete plans(to the county copy only)for the system,on paat;liat less County <br /> than 8 12 x 11 inches in size. (�10�& <br /> • See reverse side for instructions for completing this application S ate Sanitla/ry�Per'mit Number <br /> The information you provide may be used by other government agency programs ❑Check �evision tO previous application <br /> [Privacy Law,s. 15.04(1)(m)J. <br /> State Plan LD-Number <br /> 1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Prope Owner Name Property Location <br /> [Q 1/4 1/4,S Z T ,N, R 1, E(o W <br /> Prop rty Owner's Mailing Address Lot Number Block Number <br /> 27I U N Co L-N CT- I U <br /> City,StateZip Code I Phone Number Subdivisio Name or CSM Number <br /> II. TYPE F BUILDING: (check one) ❑ State Owned L] CityNearest Road <br /> ❑ Village LA �UV <br /> Public 1 or 2 FamilyDwellingNo. of bedrooms Town of Ll/ <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax(NNuummber(s) <br /> 1 ❑ Apartment/Condo I "'r �ZZE `JL © <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. gNew 2. ❑ Replacement 3. E] Replacementof 4- E] Reconnectionof 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 /> 121 ❑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 S. Perc. Rate 6. System Elev. 7. Final Grade <br /> Required (sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) 2 / Elevation <br /> SO& -1 375 � �� �3- Feet $, Feet <br /> TANK Ca acit <br /> VII INFORMATION in gallons Total #of Manufacturer's Name Prefab coy_ steel Fiber- Exper <br /> Gallons Tanks Concrete glass Plastic App <br /> New Existin strutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ 1 ❑ ❑ <br /> Vill. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plu er's Name:(Priv ) Plum ber',s Signature ( o tamps) MP/MPRSW No.: Business Phone Number: <br /> tc �34 -6 - <br /> PI mber'sAddress(Street Cit ,Ute,Zie): <br /> IX COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Issuing Agent Signature(No Stamps) <br /> Approved ❑Owner Given Initial Surcharge Fee) I ) <br /> Adverse Determination l at), /Q -7 <br /> X. <br /> CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.05194) DISTRIBUTION: Original to County,One copy To: Safety&Buildings Division,Owner,Plumber <br />