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ON COMPUTER/SCANNED 0)) Com, V, <br /> - Safety and Buildings Division <br /> •MALFI 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 / <br /> than 8112 x 11 inches in size. �`N� <br /> • See reverse side for instructions for completing this application StatesanitPerin It Number <br /> 9c�, <br /> The information you provide maybe used by other government agency programs ❑check it revision to Vrevious aVPlicatiun <br /> (Privacy Law,s. 15.04(1)(m)I. <br /> State Plan LD.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION — <br /> Property Owner Name Property Location <br /> L 44 ) reNC p +V tt/4 S 1/4,5; 5 T ,N, R75- E(or <br /> Property Owner's Mailing Address Lot Number Block Number <br /> Cla,yy,State Zip Code Phone Number Subdivision Name or CSM Number <br /> /Jrrrlg J �cni <br /> e,-)-F S3S3 c (G0&)77x`-3385 U 9 j0 1,;2P <br /> 11. TYPE—OF BUILDING: (check one) ❑ State Owned D City Nearest Road <br /> Public 1 or 2 FamilyDwelling- No.of bedrooms ° Towao or <br /> 111. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> C) /�a yea a 4` 900) <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. (g Replacement 3. ❑ Replacement of 4. ❑ Reconnection of S. ❑ Repair of an <br /> ------ -------- ------------- <br /> System System Tank Only Existing System Existing System <br /> ---- ------ - <br /> B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued <br /> V. TYPE OF SYSTEM: (Check only one) <br /> Nom Pressurized Distribution Pressurized Distribution Experimental Other <br /> 11 M 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 /> 2. Absorp.Area 3. Absorp.Area 4. Loading Rate S. Perc. Rate 6. System Elev. 7. Final Grade <br /> U Required(sq. ft J Proposed(sq.ft.) (Gals/day/sq.ft-) (Min./inch) q °/ a Elevation <br /> 5-0 3 Y � 9 — 5V $ Feet , Feet <br /> 1. Gallons Per D7 <br /> Ca acit <br /> VII. INFORMATION in gallons Total #of Manufacturer's Name Prefab coo, steel Fiber- Plastic Exper <br /> New Existin Gdllons Tanks Concrete strutted glass <br /> App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank OOJ fLnUa ? ® ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber '400 600 ❑ ❑ I ❑ ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> 1,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 tamps) MP/MPRSW No.: Business Phone Number: <br /> Ice <br /> PI um tier's Add rens(Street,City,State,Zi p Code): <br /> ,00 ><- 5_/f Si%eti ZJT 7.;;2 <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee linduaes groundwater ates ue Issuing Agent ignatur (No s) <br /> Sur<narge Veel <br /> J�Wrovecl ❑Owner Given Initial jsp Adverse Determination U / <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SH[)-6398(0. 05/94) MINIBUTION. Origlnaito Gn:nly,0ne<npy T. S�IetyBPuiLlings O'm::.:on,nwner,PlumGar <br />