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Eil ct�YI <br /> �• Safety and Buildings Division (� <br /> r.■Li�ii SANITARY PERMIT APPLICATION Bureau ofOuiId,ngWaterSysteml <br /> 201 E.Washington Ave. /V� <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 <br /> f'/( j�� may )/ <br /> than 8112 x 11 inches in size. 1/�G �f� L y <br /> • See reverse side for instructions for completing this application State Sanitary Perini tyumber <br /> The information you provide may be used by other government agency programsiZj // II <br /> [Privacy Law,s. 15.04(1)(m)1. t � El Ch k I reel ion Io previous application <br /> �I LbEl <br /> Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION 33 4�' 3_2 <br /> Pr erty ner arre Proper Location <br /> S S 1/4 1/4,S Z T 3 7,N, R l S'.E-(-9 }W <br /> Property Owner's Mailing Add r ss CI Lett N�LAMIW Block Number <br /> 'r e SCJ OW:�"Js <br /> City,St to Zip Code Phone Number Subdivis eor CSM Number <br /> o <br /> II. TYPE F BU DING: (check one) ❑ State Owned ❑ itY � " Nearest Road <br /> Public 1 or 2 FamilyDwelling- No.of bedrooms ❑ village (( <br /> Town OF ![d� /ilC h-f L/ .P y'.tm- �72c1 <br /> III. BUILDING U : (If building type is public,check all that apply) Parcel TaaxNumber(s) <br /> 1 ❑ Apartment/Condo O 3q— 05 Y`c6 <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_ Weplacement 3. ❑ Replacement of q ❑ Reconnection of 5. ❑ y <br /> Repair of an <br /> ------System gY <br /> System 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 []Mound 30❑Specify Type 41Holding Tank <br /> 12 E]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 /> ,/,S-071 <br /> F� Required (sq. ft. Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) v <br /> Feet Feet <br /> VII. TANK Capacity <br /> INFORMATION in gallons Total #of Manufacturer's Name Prefab. site Fiber- Ex er <br /> New ExistIn Gallons Tanks Concrete Con- Steel glass Plastic App - <br /> Tanks Tanks strutted <br /> Septic Tank r Holding Tan t/�F <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibil ty for install tion of the onsite sewage system shown on the attached plans. <br /> Plumber's Name:( ri Plu ber's natur : Stamps) MP/MPRSWNo.: Business Phone Number: <br /> PI mber's Address(St ree ty, tate Zip Code <br /> �'n-j A __L� <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> Disa roved unaae,c.o"Indwater ate s e <br /> pp Sanitary Pe �e jcbarge fee) ssuin A nt Sig to Stamps) <br /> Approved ❑Owner Given Initial lA�/ p" <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR ISAPPROVAL: <br /> SBD-6398(1.05/ 4) DISMIBUTION: Original m Count v,Dne<.,To: Safety 8 euikhi o Division,owner,Plumber <br />