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Ccn�D <br /> J <br /> Safety and Buildings Division <br /> r��■ r.r. 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 8 112 x 11 inches in size. GGl-K C f'�' a266-767 <br /> Sanitary Pe m <br /> • See reverse side for instructions for completing this application State 3ait No ber <br /> o� <br /> The information you provide may be used by other government agency programs ❑Check if revision to previous application <br /> [Privacy Law,s. 15.04(1)(m)]. <br /> State Plan I.D.Number I <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property wner Name Property Location <br /> L i 11 C 1/4 1/4,S (Z T37 N, R W <br /> Prop�rty Owner's Mailing A ss S�1� PS ZLot Num im /I U� BIOCk Number <br /> City,State dr' ip—CoCoe Phone Number Subd visio Nal► e oorrJ,CSM Number <br /> Mlltweaahikla-S_41Z (612- —007 <br /> II. TYPE OFBUILDING: (check one) ❑ State Owned o vila a Nearest Road <br /> Public 1 or 2 FamilyDwelling- No.of bedrooms town of <br /> Ill. BUILDING USE: (If building type is public,check all that apply) Parcel Tax <br /> Number(s) <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. %Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> E <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 Doolding Tank <br /> 12❑Seepage Trench 22❑In-Ground Pressure 42 b 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. Pert. Rate 6. System Elev. 7. Final Grade <br /> Required(sq.ft.) Proposed(sq.ft.) Gals/da /sq.ft.) (Min./inch) Elevation <br /> eet Feet <br /> Cact <br /> VII. Capact <br /> in gallo s Total #of Manufacturer's Name Prefab. Cote Steel Fiber- plastic Exper. <br /> New Existin Gallons Tanks Concrete strutted glass App. <br /> Tanks Tanks / <br /> Septic Tank Holding Tan ��� [ `(e-WI" F,Q 171 11 11 1:1 ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsi ility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Nam :(Pint) PI mber'sSignatue: oStamps) MP/MPRSWNo.: Business Phone Number: <br /> �S V)`2'v- 4- IIS$ S 7�� 6 <br /> Plum Fs Address's <br /> et sty State,2 I (ode): �r r <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Age. Signature(N <br /> /tea <br /> Approved ❑ efee) 7/� <br /> Owner Given Initial /p <br /> Adverse Determination 77 <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.05/94) DISTRIBUTION: Original to County,One copy To: Safety B Ruildings Divi ion,Owner,Plumber <br />