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Safety and Buildings Di <br /> ron <br /> SANITARY PERMIT APPLICATION Bureau of Building water Systems <br /> In accord with ILHR 83.05,Wis.Adm.Code 201 E.Washington Ave. <br /> P.0-Box 7969 <br /> Madison,WI 53707-7969 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less cou ty <br /> than 8 1/2 x 11 inches in size. 41 <br /> fy N Q <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> The information you provide may be used by other government agency programs 36 16 -717 (� <br /> I Privacy Law,s- 15.04(1)(m)]. ❑Check it revision to previous application <br /> State Plan I.D.NumberO <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION- <br /> Pro erty Owner Name Property Location <br /> D()it- NJ.r . t) 1/4 1/4,S .3V T 5iO ,Nr R /-5-E(or w5 U'I <br /> Property Owner's Mailing A dryss Lot Number„ <br /> Block Number <br /> Zip Code <br /> City,Stat G' 7Phone Number Subdivision Name or CSM Number <br /> i <br /> Ori c 6..)_X_, SYP3 ( ) a7�J � v a 2 I n < L <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ city Nearest Road <br /> Public 1 or 2 Family—Dwelling - No. of bedrooms o� E] village J(�� <br /> Town OF ��L.1\)O'� <br /> ArAyll- <br /> Ill. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s)I ' <br /> 1 E] Apartment/Condo �' — ` 5 �oj400 <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 <br /> El 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 System 2. E] Replacement 3- ❑ Replacement of 4- ❑ Reconnection of 5- ❑ Repair of an <br /> ______ --------_y ------------- 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 /> Non-Pressurized Distribution Pressurized Distribution Experimental Other <br /> 11Seepage Bed 21 E]Mound 30❑Specify Type 41 E] 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 /> Jo2D� Required (sq- ft.) Proposed(sq.ft.) (Gals/day/sq. ft.) (Min./inch) q Elevation <br /> a rf' a f /�- Feet r�•� Feet <br /> VII. TANK Capacity <br /> INFORMATION in gallons Total #of Manufacturer's Name Prefab Site Fiber- Exper <br /> New ExistingGallons Tanks Concrete Con- glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank Cy �O G ❑ pt ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ �` ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT Ej <br /> 11 <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name:(Print) 6 .. Plumber's Signature:( o Stamp MP/MPRSW No.: Business Phone Number4 CSL L� X36' <br /> Plumber's Address(Street,Cityate,ZF Code): <br /> >Q © -:S S ..? S f} <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued----]Issuing A ent natur s) <br />, rprvved ❑OwnerGivenlnitial � '°rcnargeFee) <br />-� VV Adverse Determination j 6 ld�� <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVALT <br /> : <br /> SHU-6398(8.05/94) DISTRIBUTION: Original D)county.One ropy To: Safety&Buildings Division,Owner,Plumber <br />