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_ Safety and Buildings Division <br /> itCa.Fi: 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 /> Madison,WI 53707-7,969 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County <br /> than 8 1/2 x 11 inches in size. et0/'/Ve-- / _ <br /> • See reverse side for instructions for completing this application State Sanniitaarryy Peerrrm�iitt�7Number <br /> The information you provide may be used by other government agency programs p Check it revisi n to previous application <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property OwnerNa / Propert�Location ,.,,�; <br /> /4-C / e �t/4 ,P 1/4,S Ta78 ,N, R/_T_E(o" <br /> Property Owner's Mailing Address Lot Number Block Number <br /> �`. C AAJ",J,4 ,u a <br /> City,State d Zip Code Phone Number �/ Subdi ame or CSM Number <br /> L- L� N4.4 �. SS (��.1} - -3,7 is I <br /> II. TYPE OF DING: (check one) ❑ State Owned ' Cit( r Nearest Road <br /> Public or 2 FamilyDwelling- No. of bedrooms L Twn oFL <br /> M. BUILDIN USE. Ifbuildingtypeispublic,checkallthatapply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo C>141—Je)_:5rb <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_ c7l Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> System r—System Tank Only---------------Existing System ______ExistingSystem <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 A5eepage 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 /> Required (sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> C® r; -:2 — 91. 1! Feet 9�l 9 Feet <br /> Capact VII INFORMATION in gallons Total #of Manufacturer's Name Confab Site Con- Steel glass plastic Aper <br /> Gallons Tanks Concrete glass App <br /> New Existin strutted <br /> Tanksl Tanks �q <br /> Septic Tank or Holding Tank 75-0 7-5-Z) / P1El El EJ El El Pump Tank/Siphon Chamber �l C� <j e J RL ❑ ❑ ❑ ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT t <br /> I,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 Stamps) MP/MPRSW No.: Business Phone Number: <br /> Plumber's Address(Street,City,State,Zip Code): <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> E]Disapproved Sanitary Permit Fee flndudesGroundwater ate slue Issuing A entSignature(NoStamps) <br /> Surcharge Fee) e <br /> )(Approved ❑Owner Given Initial � /Jb-a/-E��, <br /> Adverse Determination <br /> CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.05/94) DISTRIBUTION: Original b>County,One copy To: Safety&8uildings Division,Owner,Plumber <br />