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^,,. Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION Bureau ofBuildingWaterSystems <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 81/2 x 11 inches in size. /` ( ( T <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> The information you provide maybe used by other government agency programs ❑Gin revision 16 previ application <br /> [Privacy Law s- 15.04(1)(m)]. State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Name Property Location <br /> Am e S i4nJ Till <br /> 1. 52,1 114Wcd 1/4,S 2,. T N, R/ E(or <br /> Property Owner's Mailing Address Lot Number Block Number <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> II. TYE FBUILDING: (check one) ❑ State Owned ❑ ity Nearest Road <br /> 3 C] Village rQ A <br /> Public 1 or 2 FamilyDwelling- No.of bedrooms Town OF Ill Y S I�in1 e ll <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo oac) 3/ <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. pS Replacement 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 [K 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 S. Perc. Rate 6. System Elev. 7. Final Grade <br /> S Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq. ft.) (Min./inch) Elevation <br /> y o loy� lv YS' . GT — Feet 7 Feet <br /> Ca aclt <br /> VII. TANK in allons Total #of Prefab. Site Fiber- Exper <br /> INFORMATION 9 Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> New Existin structed <br /> Tanks Tanks <br /> Septic Tank or Holding Tank /2l0 �o��p l drlI n I El 0 <br /> Lift Pump Tank/Siphon Chamber F-1 F1 Ej El E] Il <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)P Plumber's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> PI u ber's Address(Street,City,State,Zip Code): <br /> Xd 3%y S//`e Z-1 li---/77— 5�F -:2 <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (lo<wde Groundwawr I Date/su Issuing Signa e( MIPs) <br /> gkAroved Q✓ o,cnargefee) , /� <br /> pp ❑Owner Givenlnitial <br /> Adverse Determination ! �t <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398111 05,14) DISTRIBUTION: Original to Court ,0ne c4P.To: Setety a BuiWings Division,Owne<Plumbs, <br />