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_ Safety and Buildings Division <br /> V��Lrin SANITARY PERMIT APPLICATION Bureau Building Water Systems <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 /> r Attach complete plans(to the county copy only)for the system,on paper not less count c� <br /> than 8 1/2 x 11 inches in size. E!�/I/ P �6 ` <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> 6 &�5 <br /> The information you provide maybe used by other government agency programs ❑Che evision to previous application <br /> lPrivacy Law,s. 15.04(1)(m)I. State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner NameI - Property Location <br /> 7 E � ALd1/4 /1)15114,S 2? TYL) N, Rlt E(or D <br /> Property Owner's Mailing Ad re r Lot Number _ Block Number <br /> City,State Zip Code Phone Number!7%"Jz Subdivision Name or CSM Number <br /> 0eb51;e_,, syS73 �? ( )9641(-7Y.01 -' <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ ity LNear st oad n / <br /> Public 1 or 2 Famil Dwellin No.of bedrooms ' e Tolwn of �gc, So"� p <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s)) / <br /> 1 ❑ Apartment/Condo I0lc2 <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. E] Replacement 3. E] Replacement of 4. ❑ Reconnection of S. E] 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 XSeepage 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 5. Perc. Rate 6. System Elev. 7. Final Grade <br /> C/ � Re wired(sq.ft.) Proposed(sq.ft.) (Gals/day/sq. ft.) (Min./inch) q Elevation <br /> 7 Q G�c) s $� /�5 Feet )J- 9 Feet <br /> VII. TANK Capacity Site <br /> in gallons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- plastic Aperp- <br /> INFORMATION Gallons Tanks Concrete glass App. <br /> New Existin strutted <br /> Tanks Tanks J _ <br /> Septic Tank or Holding Tank le0o <br /> Litt Pump Tank/Siphon Chamber ❑ 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:(No Stamps) MP/MPRSW No.: YB�Usi;ne;ss�P;hone Number: <br /> Plumber's Address(Street,City,State,Zip Code): <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (iMWdeSGroundwater ate Issue Issumg Age i ature( o ) <br /> roved sur<narge lee) <br /> pp ❑Owner Given Initial p <br /> Adverse Determination 1150/UUa— <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBU-6398(B.05/94) DISTRIBUTION. Original to Caanl y,One u.py To: s.f.ty B 8,55mge nivulon,flwneq Plumtur <br />