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T � k)T fu no Safetyand Build in s Division <br /> ir��'■:: SANITARY PERMIT APPLICATION l/J " Bureaof Building Water System! <br /> ,� V 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. Q <br /> • See reverse side for instructions for completing this application State sanitary PerrmZber <br /> The information you provide may be used by other government agency programs '44`� <br /> 9 Y rams P 9 ❑Check d revision to previous application <br /> (Privacy Law,s. 15.04(1)(m)]. <br /> State Plan IRm¢eJ=�o 6 <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION Vr/7 67 <br /> Pro pe y Owner ame Property Location U / <br /> �=/l r/�i S 1/4 114,S �a5 T / ,N, R/14 E <br /> Property Owner's Mailing Address n� LotNumberp,� </tJ Block Number <br /> City,State Zip_Code Phone Numb r Subdivision Name or CSM Number <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ City Nearest Road / <br /> ❑ Towne <br /> �- x J C}1 KE <br /> Public 1 or 2 FamilyDwelling- No.of bedrooms �,_ town of ��1�1 ���✓c� �� o<;,� <br /> III. BUILDING USE: (if buildingtype is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo p - `/j I;? .: O <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 online B,if applicable) <br /> A) 1. ❑ New 2. Ug Replacement 3. ❑ 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 ba 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 5. Perc. Rate 6. System Elev. 7. Final Grade <br /> Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation_ <br /> -�z lb1,1.2 Feet /D3 f Feet <br /> VII. TANK Capacity <br /> INFORMATION in gallons Total #of Manufacturer's Name Prefab. Site Fiber- Exper <br /> Gallons Tanks Con- Steel Plastic p <br /> New Existin Concrete strutted glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank <br /> Lift Pump Tank/Siphon Chamber x"00 r 00 ❑ El El ❑ Q <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:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> Plumber's Address(Street,City,State,Zip Code): <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (Includes Groundwater ate slue Issuing Ag lgnat ps) <br /> roved hargeree) ry <br /> PP E]Owner Given Initial [� <br /> Adverse Determination 71 <br /> X. CONDITIONS OF APPROVAL/REASONS FOR ISAPPROVAL: <br /> SBD-6398 in,05194) DISTRIBUTION- original to County,One copy To: Safety&Buildings Division,owner,Plumber <br />