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_ W 1 ► <br /> SANITARY PERMIT APPLICATION Safetya)f [dhn 'sD:vision <br /> �t�LAR Bureau of Building Water Systems <br /> In accord with[LHR 83 05,Wis.Adm.Code 201 E.Washington Ave. <br /> 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 1/2 x 11 inches in size. a �� �T <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> The information you provide may be used by other government agency programs I-7 <br /> [Privacy Law,s. 15.04(1)(m)1. E]Check it revision to 2,vious application <br /> � <br /> I. APPLICATION INFORMATION- PLEASE PRINT ALL INFORMATION State Plan I.D.Number <br /> Property Owner Name Property Location <br /> 0 14 9roc, jAJ 4)w1/4S�J 1/4,5 3 r) Tj 7 ,N, R >y E(or)@ <br /> Property Owner's Mailing Address �7 Lot Number Block Number <br /> Z/Unl �lh�e Tile So. <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> C4 <br /> e Ca�r✓.,e /11nJ. j (&ice )yam�_6yg <br /> II. TYPE UF BUILDING: (check one) ❑ State Owned ❑ it� Nearest Road <br /> Public 1 or 2 Family Dwelling-No.of bedrooms ❑ VRage QQ !a <br /> �— Town OF cfS� ,(Jj <br /> BUILDING USE: (If building type is public,check all that alr^Ch ivLrFfo ell <br /> III. apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo C�q— 3���—Da� � <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: (Che(k only one box on line A. Check box on line B, if applicable) <br /> A) 1. ❑ New 2. jg Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5_ ❑ Repair of an <br /> ------System <br /> ________System TankOnl______________ _ Y________ Existing SystemExisting System <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 /> 110 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 5. Perc. Rate 6. System Elev. 7. Final Grade <br /> o © Required(sq.ft.) Proposed(sq. ft-) (Gals/day/sq.ft.) (Min./inch) 9u Elevation <br /> y�_'26 // Feet y�6 Feet <br /> VII. TANK Capacity <br /> INFORMATION in gallons Total #of Prefab. Site Fiber- Exper <br /> Gallons Tanks Manufacturer's Name Con- glass Plastic App <br /> New Exlstin Concrete strutted Steel <br /> Tanks Tanks <br /> Septic Tank or Holding Tank ?Ott go a 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 /> 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 IssuedIss Agent ignatu re(No Stamps) <br /> Approved ❑Owner Given Initial �} Surcharge Fee) <br /> Ad verse Determination �'" I ' �� '��� <br /> /.� NDLLITIONSO,F APPROVAL/REASONS FOR DISAPPROVAL: <br /> L� rP (S f16-f— <br /> "6441 rhe I r���%d�.J ((lt Bd C1Lj-A1/1 <br /> SBD-6398 IF,05/94) 1 DISTRIBUTION: Original to County,One COPY To: Satety&Buildings Division,Owner,Plumber <br />