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C)0 CA,) z <br /> Safety and Buildings Div sloe <br /> .y. .,r. SANITARY PERMIT APPLICATION Bureau of Building Water Systems <br /> 201 E-Washington Ave <br /> Inaccord 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 Count <br /> than 8 112 x 11 inches in size. tri ic)e_ 6 <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number Q <br /> The information you provide maybe used by other government agency programs ❑Check if revision to previous application <br /> (Privacy Law,s. 15.04(1)(m)I_ State Plan I.D.Number n <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION17 I <br /> Property Ow er Name Property Loc ion ti, ll'' <br /> --1/4,5 T y(1 ,N, R /�E(oryV.13 <br /> Property Owner's Mailing Address �� Lot Number Block Number _ <br /> 'T <br /> City,State .//g Zip Code Phone Number Suhd vi—n mo n,CSM Numher 407—a CS/� <br /> Le- <br /> � ot y, �-o yy c6/� >Y�'l-�7s� o le Lx Sccii6i. v- 1 (a_P:1D, <br /> II. TYPE )F BUILDING: (check one) ❑ State Owned El CtVil� G Nearest Road <br /> ❑ ae <br /> Public or 2 FamilyDwelling- No.of bedrooms 5 Town 0 ,,AC �s0'1 ,0, u i E?, t^ <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumher(s) <br /> —0l <br /> 1 ❑ Apartment/Condo I <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 /> 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 D.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 /> Required(sq. ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> YOU pQp ©0 Feet Y Feet <br /> Capacity VII. FORMATION in gallons Total #of Manufacturer's Name Prefab con- Steel Fiber- Plastic Exper. <br /> New ExistingGallons Tanks Concrete strutted glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank eeG) &Teo ❑ ElF-1 ❑ 1:1 <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plum/berg's Name:(Print) / Plumber's Signature (No Stamps) MP/MPRSW No,: / Business Phone Number: <br /> Liv o�� �C��f�lo�rh r:c 0 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (Indudes�roundwater ate Issue IssuingAge Sign ture o amps) <br /> Approved ❑Owner Given Initial s r< gaFeel !9 <br /> Adverse Determination ZJ <br /> X. CONDITIONS OF APPROVAL/REASONS FOK DISAPPROVAL: <br /> SHD-6398(R.W94) DISTRIBUTION_ Original to CmvJy,One ro py To: Surety$Ruili ings nivuion,Owner,Plumber <br />