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_ Safety and B QA ision <br /> SANITARY PERMIT APPLICATION Bureau 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 MPlan <br /> C�2!j <br /> than 8 112 x 11 inches in size. ermit Number• See reverse side for instructions for completing this application ��The information you provide may be used by other government agency programs n'to previous ap <br /> [Privacy Law,s. 15.04(1)(m)1. umber <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION —� <br /> Property Owner Name Property Location <br /> 1/4 1/4,5 T �� N, R (lo E(or W <br /> Property Owner s Mailing Address Lot Number <br /> 5 Pone Number Subdivision Name or CLS Number <br /> Cit ,State Nr Zi Code ( IZ) - L6N 1QES <br /> Y s �' �� ❑ city Nearest Road <br /> II. TYPE BUILDING: (check one) E] State Owned 3village <br /> Public &r 1 or 2 Family Dwelling-No.of bedrooms own OF SWISS <br /> III. BUILDING USE: (If building type is public, Parcel Tax Number(s) <br /> ,checkallthatapply) <br /> 6 3�- <br /> 1 ❑ Apartment/Condo <br /> 2 E] Assembly Hall 6 ❑ 10 Medical Facility/ 11 ❑ Outdoor Recreational Facility <br /> 3 E] Campground 7 ❑ Merchandise: Sales/Repairs E] 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) Repair of an <br /> New 2. Replacement 3- ❑ Replacement of 4. E] Reconnection of 5. E] p <br /> A) 1. ❑ Tank OnlyExistin System Existing System <br /> System ____ <br /> -------- -------------------9 ----- <br /> ---------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 /> ❑Mound 11 K Seepage Bed 21 Md 30 E]Specify Type 41 [-]Holding Tank <br /> 42 C]Pit Privy <br /> 12 E]Seepage Trench 22❑In-Ground Pressure 43 E]Vault Privy <br /> 13❑Seepage Pit <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. Elev(ati1 Grade <br /> 1 _ Required(sq. ft.) Prop�sgd$(sq.ft.) (Gals/y/sq.ft.)( Min./inch) <br /> �p 3 'f � p1� 101- 6 Feet 10Z. 1 Feet <br /> VII. TANK Capacity Site Fiber- Exper. <br /> in gallons Total #of Manufacturer's Name Concrete ete Con- Steel glass Plastic App <br /> INFORMATION New Existin Gallons Tanks strutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank llxO cod El El Q El <br /> ❑ E] r-1 rj <br /> lI US <br /> left 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 Signature'(N tamps) MP/MPRSW No.: Business Phone Number: <br /> Plumber's Name:(Pnnt) WLfA 3L/z6 9/� O/6- ��s'� <br /> `t f)�O <br /> P umber's Address(Street,City,S ate,Zip Code): <br /> w 3'CI��B W(. 5 8113 <br /> IX. COUNTY/DEPARTM NT USE ONLY <br /> Disapproved Sanitary Permit E(Indude5Gr=oundwaterate <br /> uing A ign ps) <br /> ❑ pp �pproved ❑Owner Given Initial <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R 05/94) DISTRIBUTION: Original to county.one copy To: Safety&Buildings Division,owner,Plumber <br />