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i <br /> SafetyandBuIIdings ivisloin <br /> �•1�•�•. SANITARY PERMIT APPLICATION Bureau of Building Water Systems <br /> In accord with ILHR 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 8112 x 11 inches in size. ups. e:;? /o2L <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 W (/p <br /> [Privacy Law,s. 15.04(1)(m)]. ❑Check if rewous application <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION- PLEASE PRINT ALL INFORMATION <br /> Property Owner Name Property Location <br /> E 1/4 1/4,S 2g T3% ,Nr R I7 E(oW <br /> Property wner'sMailing Addre Lot Number mer <br /> 231 OL.D -3s- <br /> ZIP <br /> S CL 1 L. I <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> W I• <br /> S48-72- (11!;)663-2647 CSM P- 174 <br /> 11. TYPE OF BUILDING: (check one) ❑ State Owned ❑ villity Nearest Road <br /> Public 1 or 2 Famil Dwellin - No.of bedrooms 3 age QLD 35 <br /> n <br /> TowOF JQIVIE <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo 24-219 02. ioo <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________ ______________ ___ YgSstem ExistinSystem <br /> _______________Existiny ___ ______ ----9----- <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 N 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 Rate5. Perc. Rate 6. System Elev. 7. Final Grade <br /> Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> `t.6(/ 643 6413 .7 `�_ 43.4 Feet 95.1 Feet <br /> VII. TANK Capacity <br /> INFORMATION in gallons Tota] #of Manufacturers NPrefab. Site Fiber- Ex er <br /> New Existinganuacurersame <br /> Gallons Tanks Concrete Con- Steel glass Plastic App <br /> Tanks Tanks structed <br /> Septic Tank or Holding Tank 1000 1006 1 5K�1✓ <br /> Lift Pump Tank/Siphon Chamber El Q El El ❑ ❑ <br /> Vill. 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:(NoS amps) MP/MPRSW No.: Business Phone Number: <br /> I cN�kF2v OPKaP/S -i( 3426 'SIS - 866. 4157 <br /> Plumber's Address(Street,City,State, ip Code): <br /> 2'17(Do -w 35 X466 Mrz Wt . 548413 <br /> IX. COUNTY/DEPARTMEN USE ONLY <br /> El Disapproved Sanitary Permit Fee ("dudes Groundwater ate ssue Issuing Ag t gna ure tamps) <br /> Surcharge Fee)+-p-proved ❑Owner Given Initial /�a <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.05/94) DISTRIBUTION: Original to County.One copy To: Safety&Buildings Division,Owner,Plumber <br />