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g' Safe, and Buildings Divi ion <br /> isF3 SANITARY PERMIT APPLICATIO Burea of Building Water System: <br /> 201 E Washington Ave. <br /> In accord with[LHR 83.05,Wis.Adm.Code P O- ox 7969 <br /> ison,WI 53707-7969 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less <br /> than 81/2 x 11 inches in size. <br /> • See reverse side for instructions for completing this application State Sanitary Peerrrmiitt Number <br /> The information you provide may be used by other government agency programs ❑check it revision t' o previous <br /> application <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION -7" J65-32___, <br /> Property Owner Name Property Location <br /> ERu OL50 A/ 1/4 1/4,5 ZS T N, R E(or(w) <br /> Property Owner's Mailing Address Lot Number Block Number <br /> City State Zi Code P one Number Subdivis n Name or SM u ber <br /> 0 ( 2D> 5 �1 <br /> Ill. TYPE BUILDING: (check one) ❑ State Owned ❑ City Nearest Road <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms Z Village 'O� �. FF <br /> Town OF <br /> III. BUILDING USE: (if buildingtypeispublic,check allthatapply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo D� 9(ZS 61 zoo <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- IgReplacement 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 /> 11 [-]Seepage Bed 21 [:]Mound 30❑Specify Type 41 ❑Holding Tank <br /> 12❑Seepage Trench 224 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 /> Required (sq. ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> Feet Feet <br /> Ca acit <br /> VII. N ORMATION in gallons Total #of Manufacturer's Name Prefab. SiteCon- Steel Fiber- Plastic Exper <br /> New Existin Gallons Tanks Concrete strutted Blass App. <br /> Tanks Tanks <br /> IL <br /> Septic Tank or Holding Tank M 1 <br /> [T56 ❑ ❑ E] E] 1:1Lift Pump Tank/Siphon Chamber � �� ❑ ❑ I ❑ 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/MPRSWNo.: Business Phone Number: <br /> ►c b 0 <br /> _347-4 8(P6- IS <br /> PI mber'sAddress(Street,City tate,Zip Code): <br /> 2,7AQ 35- V,�951 W►• <br /> IX. COUNTY/DEPART ENT USE ONLY <br /> ❑Disapproved SanPermit Fee (�"dudescrovndwater ate sed Issuin en igna re(IN ps) <br /> ClIkApproved F1 Owner Given Initial itar ALJ/ 2:r_1 <br /> :r_ Surcharge Fee) <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR ISAPPROVAL: <br /> SBD-6398(R.05/94) DISTRIBUTION: Original to County,One copy To: Safety&Buildings Division,Owner,Plumber <br />