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T-);7 Ctr,.�')L-/:,f, <br /> Safety and Buildings Division <br /> E <br /> SANITARY PERMIT APPLICATION Bureau of BuildinnWater 5201 E Washingt Ave. <br /> Systems <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 Coun a <br /> than 81/2 x 11 inches in size. <br /> • See reverse side for instructions for completing this application State 5anita.y Pe To t NumbeIr <br /> The information you provide may be used by other government agency programs ❑Chec�evvviiision to pre cis application <br /> [Privacy Laws. 15.04(7)(m)1- State PI nI.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION 6 ,3 70 <br /> Pro erty Owner Name Property Location <br /> Tee— d (�J C, /4,STay ,N, R E(or) <br /> Property Owner's Mailing Address p / Lot Number Block Number <br /> -S; v L /1 <br /> City,State Zip Code Phone NumberS - eor CSM/Number <br /> II. TYPE OF BU DING: (check one) ❑ State Owned [IItr ,°1 Near 5 Road <br /> Public 1 or 2 Famil Dwellin - No. of bedrooms ° Town of d h/ fu; t? <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo 1 66 - <br /> 2 <br /> 6 -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 /> S ❑ 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_ M New 2. ❑ Replacement 3- ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> I System System Tank Only Existing System Existing System <br /> S <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;N 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 /> 6 GN ` 1 —' Feet Feet <br /> Ca aclt <br /> VII. INFORMATION in gallons Total #of Manufacturer's Name Prefab Con- Steel Fiber- plastic Exper <br /> New Existin Gallons Tanks concrete strutted glass App <br /> Tanks Tanks <br /> Seitit=Laok-or Holding Tank C1P�J ,a'Dc.'>C> _� [,, ❑ ❑ ❑ ❑ ❑ <br /> I ft Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> [,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 Sta ps) MP/MPRSWNo.: Business Phone Number: <br /> Plumber's Address(Street,City,State,Zip Code): <br /> &,X S"/ f — e in..J e_—, -r f <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee tlndudes Groundwater Datq ssue I Issuing Agen Signa ure�tps) <br /> sur <br /> proved ❑Owner Given Initial mar9ereet /7U <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SRO-6398(R.05194) DISTRIBUTION: Original to county,One copy To: safety a Buildings Division,Owner,Plumber <br />