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t <br /> Safety and BuiIdin dTins <br /> Vt �•" SANITARY PERMIT APPLICATION Bureau of Building Water Systems <br /> A 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 Salwe oc c�0 <br /> than 8 1/2 x 11 inches in size. <br /> • See reverse side for instructions for completing this application State Sanitary Perm' Num er <br /> X 00 <br /> 06) <br /> The information you provide may be used by other government agency programs ❑Check if revision to previous application O <br /> (Privacy Law,s- 15.04(1)(m)]. State Plan I.D.Num er (,1 <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION U, <br /> Property Owner Name Property Location <br /> own,-L ar /_g 1/4 1/4,S jy T3F •N, R/S E(or)a <br /> Property Owner's Mailing Alffdress Lot Number Block Number <br /> X, h Gla+ 7 -ou &9' r <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> Al e 6v Yr (7i s) 9- 9 <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ city Nearest Road <br /> ❑ Village <br /> Public 1 or 2 Family Dwelling- No.of bedrooms Town OF /-a ^o//e <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo ®/ � 05 <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 EZ 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. E] Reconnection of 5_ ❑ Repair of an <br /> System ystem - Tank Only --------------Existing System _ _____ExistingSystem <br /> _ <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 yWound 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. 1 7. Final Grade <br /> Required(sq. ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> a2 Y6 < I II(d ( Ila qG .,t 2 X11 9��� Feet 94.5" Feet <br /> Capaclt <br /> VII. TANK in allons Total #Of Prefab. Site Fiber- plastic Exper <br /> INFORMATION Gallons Tanks Manufacturer's Name Concrete con- Steel glass App. <br /> New Existin strutted <br /> Tanks Tanks a I El El <br /> Septic Tank or Holding Tank 41600 7-In C <br /> Lift Pump Tank/Siphon Chamber 97F& 7-M ❑ ❑ <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'sSignature:(No Stamps) P/ PRSWNo.: - Ir Business Phone Number: <br /> Plumber's Address(Street,City,State,Zip Code): <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved anitary Permit Fee�(indudes6(oundwater at sue Issuing A ent ign r mps) <br /> Approved ' /_/ /orcharge Fee) <br /> pp ❑Owner Given Initial W <br /> Adverse Determinatio <br /> CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: If 1 1 7 <br /> R 05/94) DISTRIBUTION: Original to county,One copy To: Safety&Buildings Division,owner,Plumber <br />