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CYi <br /> Safety and Buildings IV, <br /> E, SANITARY PERMIT APPLICATION Bureau of Building Water System,. <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 /> • Attach complete plans(to the county copy only)for the system,on paper not less Count <br /> than 8 112 x 11 inches in size. • /'/J e- 0 S <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> g��� <br /> The information you provide may be used by other government agency programs ❑Check It revision to previous application <br /> [Privacy Law,s. 15.04(1)(m)]. <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Prop rty Owner ame Property Location c_ <br /> CVX/'d uove/4 e_= 1/4,S 3 (o T IN, R J�/ E(or <br /> Property Owner's Mailing Address Lot Number I Block Number <br /> Lc1 ;7 �t]C <br /> Ci y,Slate, zip Code Phone Number Subdivision Name oTE5M-N4A'ber <br /> 4,1 <br /> II. TYPE BUILDING: (check one) E] State Owned '.t Nearest Road <br /> El Village / 7 <br /> Public 1 or 2 Famil Dwellin -No. of bedrooms -� Town of <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumbbeer(s) <br /> _ <br /> 1 ❑ Apartment/Condo <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. gReplacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5. ❑ 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 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 /> Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> v �� ��� 9� Feet 9�Y Feet <br /> TANK Capacit <br /> VII INFORMATION in allons Total #of Manufacturer's Name Prefab. Con- steel Fiber- Plastic Exper. <br /> New Existin Gallons Tanks Concrete strutted glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank 00C) I ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ 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 Stamps) MP/MPRSW No.: Business Phone Number: <br /> GJ'/tal-_ /1/Slo/•s C-✓ ��G_ s 9 ��" <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 'go -5-1 y -,) L -J s <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (Includes Groundwater ate sue Issuing Agen ignatu o Stamps) <br /> •� rcharge Fee) y <br /> Approved ❑Owner Given Initial [// �� /0 / <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FORDISAPPROVAL: <br /> SRD.6398(R.05/94) DISTRIBUTION: Original to County,One copy To: Safety&Buildings Division,Owner,Plumber <br />