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LiT u�p <br /> Safety and Buildings Division <br /> �••.•• Bureau of Building SANITARY PERMIT APPLICATION 201EWashingtnAveer5ystem <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 �3 <br /> than 8 12 x 11 inches in size. 9P Iq <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> Pal• eZ„� � qSS <br /> (Privacy Law,s15.04(1)(m)]. <br /> The information you provide may be used by other government agency programs Check it revision to previous apapplication <br /> . �� revision State Plan I.D.Number/ W <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFRMAT N <br /> Property Owner Name Property Location <br /> ( 4rgSO4 1/4 1/4,S1100 <br /> T g ,N, R/7 E(or <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 2 02 RA1J ^- <br /> City,State I Zip Code Phone Number Subdivision Name or CSM Number <br /> SlR rJ 2 ( S ) -285 <br /> II. TYPE F BUILDING: (check one) ❑ State Owned ❑ ity Nearest Road <br /> Public 1 or 2 FamilyDwellingW v <br /> -No.of bedrooms O age n„Al'e- N'f <br /> 5 � m C R,0own OF <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo 07 004 23817 1800 =5 <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. K Re lacement3 E] Replacement of 4. 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 1Holding Tank <br /> 12 El 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 /> N►� Required (sq.ft.) 1 Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation <br /> Feeti Feet <br /> VII. TANK Capacity <br /> INFORMATION in gallons Total #of Manufacturer's Name Prefab. Site Fiber- plastic Exper <br /> New Existin Gallons Tanks Concrete Con- Steel glass App. <br /> Tanks Tanks svucted <br /> Septic Tank or Holding Tank KA ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber El ❑ El 0 El 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:( oS ps) MP/MPRSW No.: Business Phone Number: <br /> 1(Htgjw OP fJ X7,RX., 715- $66 /,S <br /> Plumber's Address(Street,City,Sta ,Zip Code): <br /> 2-1 "i 6o w 3,5 In garjjg 01• Sq8 3 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Samt ry Pe it ee 1l"nudes Groundwater ate Jsue Issuing tS t (N St ps) <br /> Approved ❑Owner Given Initial � � "ha`9efPe1 <br /> Adverse Determination / l <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SOD-6396 in,OSN4) DISTNIBUTION: Original to County,One copy To: Safety B Xuildings Division,Owner,Plumber <br />