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Safetyand Buildings Division <br /> �•�■�■■■+ SANITARY PERMIT APPLICATION Bureaof Building Water Systems <br /> In accord with IL IR 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 County �? <br /> than 8 112 x 11 inches in size. R � f+ p�o <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 <br /> lPrivacy Law,s. 15.04(1)(m)l. ElCheck d revision to previous application <br /> State Plan I.D.Num�bell <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION ;Z � <br /> Property Owner Name Property Location <br /> 1/4 1/4,S ( T ��j ,N, R '1 E(or)(D <br /> Property Own r'sMailin Address Lot Number jea: <br /> 1iA�C 5 _ ✓` <br /> Cit State Zip SIX ACREI� <br /> Code Pone Number Subdivision Name or CSM Number <br /> PA UL M - ` Io 85 <br /> Ii. TYPE OF BUILDING: (check one) ❑ State Owned ❑ city Nearest Road <br /> Public 1 or 2 FamilyDwelling- No.of bedrooms L 0 villTownageOF f,�I,Ar I6 <br /> L5 n Lo 3E <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax N/umber(s) <br /> 1 F1Apartment/Condo �l0 2-`115 03 (0O <br /> 2 Q Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining <br /> 4 Q Church/School 8 ❑ Mobile Home Park <br /> 5 E] Hotel/Motel 9 [-1Office/Factor 12 El Service Station/Car Wash <br /> Y 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 S stem 2. )4 Replacement 3. E] Replacementof 4. Q Reconnection of S ❑ Repair of an <br /> ------ y-------------yTank Only---------------Existing System Existing System <br /> B) Q 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 ❑Mound 30 Q Specify Type 41 ❑ Holding Tank <br /> 12 Seepage Trench 22❑In-Ground Pressure 42❑Pit Privy <br /> 13❑Seepage Pit 43 Q 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 /> Re uired(sq. ft.) Proposed(sq.ft.) (GaWday/sq.ft.) (`Main-Anch) qL� Elevation <br /> 1 1 1• Feet QG. Feet <br /> VII. TANK Capacity <br /> INFORMATION in gallons Total #of Prefab. Site Fiber- Ex <br /> New ExistingGallons Tanks Manufacturer s Name concrete con- steel Plastic per <br /> Tanks Tanks <br /> strutted glass App. <br /> Septic Tank or Holding Tank 17,570 <br /> r �Z� ❑ ❑ ❑ ❑ F1Lift Pump Tank/Siphon Chamber El 1:1 ❑ ❑ ❑ ❑ <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 amps) MP/MPRSW No.: Business Phone/Number: <br /> Plumber's Address(Street,City,State,Zip Code): wll ��� / 96b /� 7 <br /> O w S tnl65 R W(. M 3 <br /> IX .COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanita y Permit F e,(Includes Groundwater at IssuedIssuing A ent ignat e( t ) <br /> Approved ❑Owner Given Initial /f /* argeree) at <br /> Adverse Determination ! (•� <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> S80-6398(K.05/94) MIRIBUTION, Original to County,one ropy To- Safety 8 Buildings nivclon,Owner,Piurnter <br />-- I <br />