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Safety and Buildings Division <br /> C�LHR SANITARY PERMIT APPLICATION Bureau of Building Water System <br /> 201 E Washington Ave. <br /> In accord with ILH R 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 81rz x 11 inches in size. ' r+ 193©E) <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> The information you provide may be used by other government agency programs p'Etf I'revisiu�o previous application <br /> [Privacy Law,s. 15.04(1)(m)). State Plan I.D.Num ber <br /> 1. APPLICATION INFORMATION - PLEASE PRINT ALL INIF MATION <br /> Property Owner Name P operty Location <br /> RILL roili P"/ v4 v4,S 2,$ T Q ,N, R S E(or <br /> Property Ow er's Mailing Address I Lot Number Die <br /> Rv _ A <br /> City,Sta a Zi ode P ne Number p Subdivision Name or CSM Number <br /> 190 <br /> qu <br /> �tl <br /> 11. TYPE F BUILDING: (check one) ❑ State Owned ❑O CI'age Nearest Road <br /> Public 1 or 2 Family Dwelling-No.of bedrooms Z Town of SflCKSOh/ -4 <br /> III. BUILDINGUSE: (If building type is public,check all that apply) Parcel Tax Numbers) rr <br /> 1 ❑ Apartment/Condo 0� i� "'viz <br /> z <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. ❑ Replacementof 4_ ❑ Reconnection of 5. ❑ Repair of an <br /> ------Sy!aem --------System............ Tank Only - _ . Existing5ysteT ExlstingSystem <br /> e) ❑ ASanitary 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 S. Perc.Rate 6. System Elev. 7. Final Grade <br /> Requ-red(sq. ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> 300 7, O1q0. j Feet Feet <br /> TANK Ca and <br /> VII. FORMATION in gallons Total #of Manufacturer's Name Pretab. Con- Steel Fiber- Plastic Exper. <br /> New Existin Gallons Tanks concrete glass App. <br /> Tanks T nk5 strutted <br /> Septic Tank or Holding Tank ❑ 0 upd ❑ ❑ F 11 <br /> I.III Pum Tank/Siphon Chamber ❑ 11 1 El <br /> VIII. RESPONSIBILITY STATEMENT <br /> lithe undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name:(Print) Plumber's Vgnature: <br /> »vsEs, MPIMPRSWNO.: Business Phone Number:66 !S <br /> PluAberSAddren(Street,City,State,zip C <br /> e): <br /> 2-1-7&0 WX65TFZW1. -54913 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> 10 Disapproved Sanitary Permit Fee f"`iweterovnav ata ate su IssuIngA a tSign tur N Stamps) <br /> Approved ❑Owner Given Initial �O �1 S."h,r9xi�1 <br /> Adverse Determination y Z <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL; <br /> SRI)b 39B(it.Min) oisn09unox Original to County.Om myy To: Slaty a anlNh,v pivr.ian,Onao.,PlumWr <br />