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.mss. t.f r a <br /> �l ii <br /> Saetynd Building Division <br /> �t■�.,.a SANITARY PERMIT APPLICATION Bureau of Building Water$ystem <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 County /q7 <br /> than 81/2 x 11 inches in size. U J <br /> • See reverse side for instructions for completing this application ate Sanitary Permit N'Jummberr <br /> The information you provide may be used by other government agency programs <br /> (Privacy Law,s. 15.04(1)(m)111 Check it revision tO previews APPlicadon <br /> . <br /> State Plan I.D.ME <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Name Property Location <br /> r 14 /4,S q T N, R E(orye <br /> Prope�OwLn+e Mai in Address Lot Number <br /> Cit , ateL o e I Phone Number Subdivision Name or CSM Number <br /> 3 ( ) qq <br /> II. TYPE CIF BUILDING: (check one) ❑ State Owned D it' r. r Nearest Road) <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms —7-- Town OFSLO <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax`Number(s) <br /> 1 E] Apartment/Condo q0 Jl 19 07 00 OZ8 qI (9 01 <br /> 2 Q Assembly Hall 6 Q Medical Facility/Nursing Home 10 E]AOutdoor 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 online B, if applicable) <br /> A) 1. ❑ New 2. Replacement 3. Q Replacement of 4. Q Reconnection of 5. Q 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 /> Non-Pressurized Distribution Pressurized Distribution Experimental Other <br /> 11 Seepage Bed 21 ❑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 /> 3 00 Requi red(sq. ft.) Proposed(sq.ft.) (Gals/day/sq. ft.) (Min./inch) / Elevation <br /> SjZ po-S Feet ,� Feet <br /> VII. TANK Capacity <br /> INFORMATION n gallons Total #of Manufacturer's Name Prefab Con- Fiber- Plastic Exper <br /> New Existin Gallons Tanks concrete Steel glass App. <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank C) El <br /> Lift Pump Tank/Siphon Chamber El El IEl ElI El <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:(Print) Plumber' Signature: No mps) MP/MPRSW No.: Business Phone Number: <br /> c RP P l S `fZao S 66 /s <br /> PI ber's Ad ress(Street,City,Sta e,zip Code): <br /> '771ao >� 3S Wsr�iZ WI. Sy813 <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit FEW Bndudes6rroundwater ate so Issuing Age Sign re ) <br /> Surcharge Fee) <br /> pproved <br /> E]Owner Given Initial X a, <br /> Adverse Determination C� <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SOD 6398(R.05N4) DISTRIBUTION: Original to County,One cony To: Safety&Buildings Divnion,Owner,Plumber <br />