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Safety and Buildings Division <br /> CUL HR 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 County I 1 3 <br /> than 8 112 x 11 inches in size. <br /> • See reverse side for instructions for completing this application State sanitary Permit Number <br /> ,5y0y0 <br /> The information you provide may be used by other government agency programs ❑ heck it revision to previous application <br /> [Privacy Law,s. 15.04(1)(m)I. State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> PropertyOwner Name P operty Location <br /> .I vn v4,S 2,$ T Q ,N, R f,S E(or <br /> Co FZM1 <br /> Property Ow er's Mailing Address I Lot Number <br /> QS9(2 to . Ro _ A <br /> City,Stae Zi ode Ph ne Number Subdivision Name or CSM Number <br /> Er _1 OW - S 1 <br /> II. TYPE OF BUILDING: (check one) E] State Owned ❑ ity Nearest Road <br /> ❑ Village A <br /> Public 1 or 2 FamilyDwelling-No. of bedrooms Z Town of JrA(X SO/J o , A <br /> 111. BUILDING USE: (If buddingtype is public,check all thatapply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo 01 —0 I <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_ ;gRep[acement 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 /> 1 1,,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. 17. Final Grade <br /> Required (sq. ft.) Proposed(sq.ft.) (Gals/clay/sq. ft.) (Min./inch) Elevation <br /> 30 O q 7_1 430 p . Feet Feet <br /> VII. TANK Capacity Site <br /> INFORMATION in gallons Galltons Tal a of <br /> Manufacturer's Name coo Prefab <br /> Con- Steel glass Plastic Aper <br /> New Existin strutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank El Q El El EJ <br /> Lift Pump Tank/Siphon Chamber 0 El EI Ej El <br /> Vlll. 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 gnature:(N St ps) MP/MPRSW No.: Bus mess Phone Number: <br /> I OxlxtS 66 J� <br /> PIu ber's Address(Street,City,State,ZipC e): <br /> +. _540o,13 <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> E]Disapproved Sanitary Permit Fee OndudeiGmundwater atelssu Issuing Age 1Sign tui N Stamps) <br /> tyApproved / Sur(hargeree) <br /> pp ❑Owner Given Initial / Z L* Zcr <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SRI'6398 111.OS194) DI RIBUTION. Originalm Cmimy,One mPy To: SutetY BflullJingy Di­,,0w­,Plumber <br />