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Safety and Buildings Division <br /> i:7LriA SANITARY PERMIT APPLICATION Bureau of Building Water Systems <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 Countyy Q r <br /> than 8 112 x 11 inches in size. !C N /'/�s✓ � 6790 <br /> • See reverse side for instructions for completing this application State Sanitary PermitNumber <br /> The information you provide may be used by other government agency programs ❑ChecTe it Fevt nTevi'us application <br /> (Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Propert Owner Name Property Location <br /> ,/. 1/4.5 Cj 1/4,S T y0 ,N, R 5 E(or) <br /> Prop rty Owner' Mailing Address Lot Number Block Number <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ city Nearest Road /I <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms 5,Town OF A S�/y �9 1 <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> i <br /> 1 ❑ Apartment/Condo 0/,-2 4/c2/ 2" a <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_ y,� ew 2_ E] Replacement 3. [:] Replacement of 4. E] Reconnection of 5. E] Repair of an <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 /> Non-Pressurized Distribution Pressurized Distribution Experimental Other <br /> 11 ❑Seepage Bed 21 ❑Mound 30❑Specify Type 41 ❑Holding 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 S. Perc. Rate 6. System Elev. 7. Final Grade <br /> Required(sq. ft.) Proposed(sq.ft.) (Gals/day/sq. ft.) (Min./inch) Elevation <br /> Qa .1 `— �5'%� 9 6Feet �, Feet <br /> Vil.. TANK Capacity Site <br /> in gallons Total #of Manufacturer's Name Prefab Con- Steel Fiber- plastic Aper <br /> INFORMATION Gallons Tanks concrete glass App <br /> New Existing strutted <br /> Tanks Tanks p y�1 <br /> Septic Tank o nk 13,06 O d O �!/1/rGc/r <br /> Lift Pump Tank/Siphon Chamber ❑ Q [j El El 11 <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) Plumber's Signature: No Stamps) MP/MPRSWNo.: B usi ness Phone Num ber: <br /> Z,C)Ad c. <br /> Plum er's Address(Street,City,State,Zil,Code): <br /> IX. COUNTY/ D PARTMENT USE ONLY <br /> ❑Disapproved Sanitary PermitFee (includescroundwate( ate Issue Issuin A ntSig r tamp ) <br /> Surcharge ee) <br /> tiproved ❑Owner Given Initial 1�� /��740 <br /> Adverse Determination / l� fu <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> Sill)6398(R.OY94) DISTRIBUTION: Original to Cmwty.One copy To: Salety 8 Building,Division.Owner,Plumber <br />