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Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION Bureau of Building Water Systems <br /> fit�L��7 201 E.Washington Ave. <br /> In accord with ILHR 83 05,Wis.Adm.Code P.O.Box 7969 <br /> Madison,WI Y707-7969 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less count <br /> than 8 1/2 x 11 inches in size. /'� e-1-21171 <br /> • See reverse side for instructions for completing this application state Sanitary PerNur er <br /> The information you provide may be used b other government agency programs �(U� <br /> y y y g g y g ❑Check it revision to previous application (� <br /> lPrivacy Law,s. 15.04(1)(m)]. State Plan I.D.Nu ber j[ <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION �� �` � ljQc'J <br /> Property Owner Name Property Location �- <br /> C A,^-s ,"o 5 iso i0 u.: 1/4 3, 1/4,S / T 77 ,N, R/e E(or)o <br /> Property Owners Mailing Address Lot Number Block Number <br /> 0209 /h�lv Q✓" r� � .�-- <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> 4. <br /> 11. TYPE OF BUILDING: (check one) ❑ State Owned ❑ city Nearest Road 00 <br /> ❑ Village r`A- �e- /-A�Ce <br /> Public 1 or 2 FamilyDwelling- No.of bedrooms Town of T �/"/o <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Nu�lmber(s) <br /> 1 ❑ Apartment/Condo 6 3 j 127-17 c "z yP0 <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. Doeplacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> System System ____ ____ Tank Only __________ Existing System__ ______ExistingSystem <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 3Mound 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) El�e`'ation <br /> Capacity <br /> acit J. �� Feet !9' Y Feet <br /> VII. TANK in gallons Total #of Prefab. Site Fiber- Exper <br /> INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App <br /> New lExisting strutted <br /> Tanksl Tanks <br /> Septic Tank or Holding Tank /Dda lDa� ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber -`e 0 60 v ® ❑ ❑ ❑ ❑ ❑ <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 /> G.)sfofie-- ate- Gc/��� �Z-/ 3Y9-7 2 _Vc/ <br /> Plumber's Address(Street,City,State,Zip Code): <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (Indudescroundweter ate I sue Issuing Agen ignatur (N <br /> roved 102$ harge hee) <br /> ❑Owner Given Initial � 'rJ ld O7 <br /> Adverse Determinati <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> 58O-6398(R.05/94) DISTRIBUTION: Original to County,One urpy To: Safety&Ruildingf Divivon,Owner,Plumber <br />