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Safety and Buildings Division <br /> �. ; SANITARY PERMIT APPLICATION Bureau of Building Water System <br /> 201 E Washington Ave. <br /> In accord with ILHR 83.05,Wis.Adm.Code P.O.Box 7969 <br /> Ma Icon,WI 53707-7969 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County r �p <br /> than 8112 x 11 inches in size. & gged'� <br /> • See reverse side for instructions for completing this application State Sanitary Permit Numkr �07� <br /> The information you provide may be used by other government agency programs ❑Check it revision to previous applicatio <br /> (Privacy Law,s. 15.04(1)(m)l. <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION S7—2 021(en <br /> Prop rty Owner Name I Proper Loyation <br /> TdbYA19 r 10 l A JW'- />�I,f/ 1/4,5 3 T 39 ,N, R fi; E(or)W <br /> Property Owner's Mailing Address / Lot Number Block Number I <br /> OS lU r U F iv1Qa1� /_M <br /> City State Zip CodePhone Number Subdivision Name or CSM Number " <br /> VSA s (4olV 9_y 4:�SW1 V It Z � S v <br /> II. TYPE OFBUILDING: (check one) ❑ State Owned ❑ City N arest Road <br /> ❑ Village <br /> Public LK 1 or 2 Family Dwelling- No. of bedrooms Town of yc Q�jK S <br /> III. BUILDING USE: (If building type is public,check all that apply) arcel Tax Number(s) <br /> 1 ❑ Apartment/Condo - 330 ~OS �fa <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. ig Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5- ❑ Repair of an <br /> System Existing System Existing System <br /> --------------------System------------------- Tank-----Only--------------------------------------------------- <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 M Mound 30 E]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 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 /> So -7 !3 7 fo Off, !c) Feet ►I a$S Feet <br /> VII. TANK Capacity <br /> in <br /> a acitin gallons Total #OfPrefab Site Fiber- Exper <br /> INFORMATION New Existin Gallons Tanks Manufacturers Name Concrete stCon-Steel glass Plastic App <br /> Tanks Tanks <br /> Setic T k or Holding Tank �000 ( ❑ ❑ ❑ ❑ ❑ <br /> Pum ank/Siphon Chamber ow tr ` t 29 El El F-1 ❑ 1:1VnT_IRESPONSIBILITY STATEMENT Cam L9 <br /> I,the undersigned,assume responsi ility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name:(Pr t) umber's Sig to :(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> Ilrvu Y_ I P 9_q T-7 0 <br /> Plumber's Address(Street,City, Zip C e : <br /> ? qT <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved I Sanitary Permit Fe (Incudes Groundwater ate Issue Issuing Age Si atur (N t ps) <br /> roved urcnarge Fee) <br /> pp ❑Owner Given Initial /f/1, � 8/� <br /> Adverse Determination (J`� l <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBU-6398(R.05/94) DISTRIBUTION'. Original to(.ourey,One(upy To: Sutety 8 Buildings Divs ion,Owner,Plumtxr <br />