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6-nct�)-)ti ff <br /> Safety and Buildings ivision <br /> Aja"��■� Bureau of Building Water System. <br /> ��■I�r■n SANITARY PERMIT APPLICATION 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 2 r1ta( Nyle <br /> CouR p <br /> than 8 1x 1 1 inches in size. u <br /> • See reverse side for instructions for completing this application State Sanitary PerrmmitNjum r <br /> The information you provide may be used by other government agency programs E]Che1c i evisinn to previ us application <br /> (Privacy Law,s. 15.04(1)(m)). <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Propgrty Owner Name t ' roperty Location <br /> 1Q1 V ( Q��P 1/4 NE 1/4,5 TrN, R &(Irjo <br /> Property,O <br /> Glf� wyr's MJJ hnA K ddrressss n ( Lot Number Block Number <br /> ._. <br /> City,Stir ' Zrw s 9 <br /> Code P40 7 sPhone gibber p Subdivision Name or CSM Number <br /> II. TYPE OFBUILDING: (check one) ❑ State Owned ❑ Cityage =Nearestoad7 <br /> Public 1 or 2 Famil Dwellin -No.of bedrooms _� Town of <br /> III. BUILDING USE: (If buildingtypeispublic,checkallthatapply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo 010, (o ao -O oZ q0o <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-)(Replacement 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 /> Nom Pressurized Distribution Pressurized Distribution Experimental Other <br /> 11Seepage Bed 21 E]Mound 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: <br /> 1. Gallons Per Day 2. Absorp.Area 3. Absorp.Area 4. Loading Rate 5. Perc. Rate 6. System Elev- 7. Final Grade <br /> ReyProposeded (sq.ft.) (Gals/day/sq.ft.) (Min, . Elevation <br /> ©O q3Z 7 1 <br /> ?-57t? Feet '7p• <br /> Feet <br /> TANK Capact VII INFORMATION in gallo s Total #of Manufacturer's Name Prefab. Con- Steel Fiber- plastic Exper <br /> New Existin Gallons Tanks Concrete strutted glass App <br /> Tanks Tanks -�7 /�� <br /> Septic Tan r Holding Tank X / {A/t>o$�r C x ❑ ❑ ❑ ❑ ❑ <br /> Lift 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 Name: Pn ) Plu ber' ignatu oStamps) MP/MPRSWNo : Business Phone Number: <br /> �efs ( e4 aS)a9 ap <br /> Plumber's Address(Stye t,City,Sta ,Zip Cod PtCL ( � r <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Per , I1nciudescrou�dwater ate ue Issuing Age gnat S <br /> A roved � urtnarge Fee) <br /> pp ❑Owner Given Initial !� �j <br /> Adverse DeterminationZ <br /> X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: <br /> WD-6398(R.05/94) DISTRIBUTION: Original to county,One copy To Safety&Bus Wings Dwr,,on,Owner,PlamtKr <br />