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Safety and Buildings Division <br /> �ii1,■�efBureau of Building Water System! <br /> �■�r=n SANITARY PERMIT APPLICATION 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 8lrz x 11 inches in size. �.��Li Cpp�2 <br /> • See reverse side for instructions for completing this application state Sanitary PeNnit Numberas,l �S <br /> ( I11agI ) I <br /> The information you provide may be used by other government agency programs ❑Check if revisionm previous application <br /> (Privacy Laws- 15-04(1)(m)l- <br /> State Plan LD_Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Name Property Location _ <br /> 4,4 _ B U 1/4 4,5 9 T ,N, R J� E (OCW_ <br /> Property Owner's Mailing Address Lot Num ber Block Number <br /> 316 S 235 <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> II. TYPE OF ILDING: (check one) E] State Owned ❑ ity Nearest Road <br /> ❑ Village <br /> E] Public 1 or 2 FamilyDwelling- No.of bedrooms town OF �A)V-RD <br /> 111. BUILDIN USE: (If budding type is public,check all that apply) Parcel TaxNumber(s) y� <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 online B, if applicable) <br /> A) 1. ❑ New 2. ❑ Replacement 3XReplacementof 4_ ❑ Reconnection of 5- E:] Repair of an <br /> System System - / Tank OnlyExisting System Existing System <br /> B) A Sanitary Permit was previously issued. 413_`__1 <br /> 7 Permit Number 1 3 5_ Date Issued R—o2, <br /> V. TYP OF'SYSTEM: (Check only one) <br /> NonPressurizedDistribution Pressurized Distribution Experimental Other <br /> 11 ❑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 13. Absorp.Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade <br /> Required (sq. ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> Feet Feet <br /> Ca act <br /> VII. Site I <br /> FORMATION in gallons Total #of Manufacturer's Name Prefab Con- Fiber- Plastic Exper <br /> New Exist in Gallons Tanks Concrete strutted Steel glass App <br /> . <br /> Tanks Tanks ^y7 <br /> Septic Tank or Holding Tank TJ'—Q -7�V til-&74 i eaoz.. 11 ❑ El El El <br /> I ift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ <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:(Pant) Plum <br /> rt St MP/MPRSW No . Business Phone Number: <br /> A,ac44,D 0 3cY7Z 7/67-,;?44-3S 4L9� <br /> Plum er's Address(Street,City,State,Zip Code) <br /> IX COUNTY 1 DEPARTMENT USE ONLY <br /> El Disapproved Sanitary Permit Fee Imdude.Groundwater ate ssue wing Agent Signature(No Stamps) <br /> Approved Sur<harye)ee) (` <br /> pp ❑OwnerGivenInitial {# 15D-150 <br /> Adverse Determination -+l' <br /> X. CONDITIONS OF APPROVAL 1 REASONS FOR DISAPPROVAL: <br /> SHI)098(it.G5/94) DISTRIBUTION: rn,inal m County.One rn,T. Suety&8u8 k.,Dim.ron,Ower,Vlumber <br />