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Safety and Buildings Division <br /> 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 Cou <br /> than 8 112 x 11 inches in size. e <br /> • See reverse side for instructions for completing this application State anitary Permit Number <br /> SO <br /> The information you provide may be used b other government agency programs <br /> Y P Y Y 9 9 Y P 9 ❑Check I is to previous application <br /> [Privacy Law,s. 15.04(1)(m)I. 1 )r State Pla .D.N er Y' <br /> I. APPLICATION INFORM AN - PLEASE PRINT ALL INFO MATION IQ� <br /> Prope er Name ``)� tion <br /> Ye h S !� –fi r it dca /4,S 3 ' T ZC .N, R /rG` iaC "" <br /> PropertyO ner's fling WISS mbgr Block r <br /> (/ /��I u <br /> Cit State nl ry) ) ub ivisio Nameor�CSM 1t� <br /> Uir ��1 ( 5� 7` (j / <br /> E OF BUILDING: (check one) EFSiate Owned Cit y Nearest Road <br /> ❑ Public 1 or 2 FamilyDwelling- No.of bedrooms Vow9 of1G� a <br /> III. BUILDINGUSE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo I , (1J 3 J — <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. �ew 2. E] Replacement 3. E] 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 R6ound 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: �j 4 <br /> 1. Gallons Per Day 2. Absorp.Area 3. Absorp.Area 4. Loading Rate 5. Perc. Rate 6. S S e"ev. 7. Fina Grade <br /> L� 7O Required (s ft.) Proposed(sq. ft.) (Gals/day/sq. ft.) (Min./inch) E <br /> 1 �v -3-7-5 Feet �'et <br /> Capacityf <br /> VII. TANK in allo Total #of Prefab. Site Fiber- Exper <br /> INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- steel glass Plastic App <br /> New Existingstrutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank ❑ - ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber n 60. ❑ ❑ ❑ ❑ ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned, assume responsibility for installation of the onsite se age system shown on the attached plans. <br /> PI be 's Name:(Print) Plu be 's Sign ur :(No Stamps) P PRSW No.: Business Phone Number: _ <br /> U5 l ,3S c � 3, <br /> Plu tier's Add ess( tree , y,St- e,Zip Code) <br /> 1 <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> [:]Disapproved Sanitary Permit Fee (includes Groundwater Date issued Issuing Ag t Sig ture( mps) <br /> Approved ❑Owner Given Initial 2 p 2 5°"nar9elee> / p8 <br /> Adverse Determination �d (O <br /> X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: <br /> -6398(R.05/94) DISTRIBUTION: Original to(ounly.One copy To: Safety 8 Buildings nim;ion,Owner,Plumber <br />