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U)i c.t-jyv <br /> -v Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION Bureau of Building Water Systems <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 2 county ?9 7 <br /> than 8 1x 11 inches in size. z>/'/tie.. <br /> • See reverse side for instructions for completing this application StateSanitary�Permit Number' <br /> The information you provide may be used b other overnmenta enc programs t� i ���v <br /> Y P Y Y 9 agency P 9 Check if revision to previous application <br /> (Privacy Law,s. 15.04(1)(m)I_ State Plan I.D.Number <br /> 1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Prop y Owner Name Property Location ,�-'y <br /> ZIA 11 P C GAiL'� SC1/4N = 1/4,S T (IC) ,N, R/S E(oro <br /> Property Owner's Mailing Address.�j n� Lot Number Block Number <br /> 3 00_;Z,/ ZJ �// /� V G.. <br /> J ,ate Zip Code Phone Number Subdivision Name or CSM Number <br /> Gam✓ yi SGT ( ) _ <br /> II. TYPE BUILDING: (check one) ❑ State Owned 11It Nearest Road <br /> ❑ Village <br /> Public 1 or 2 FamilyDwelling5 <br /> -No.of bedrooms Town OF 54c- kS <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo 2 // <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. CK 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 /> Non-Pressurized Distribution Pressurized Distribution Experimental Other <br /> 11Seepage Bed 21 E]Mound 30 E]Specify Type 41 E]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 /> 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) Com/ Elevation <br /> �<;� UZ v G �y / , 6 Feet Feet <br /> 1. Gallons Per Da 7 <br /> Capacity <br /> VII. INFORMATION in gallons Total #of Manufacturer's Name Prefab Site CFiber- Exper <br /> New ExistingGallons Tanks ConcreteCon- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank 00c) a ❑ ElEl ❑ El <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 /> Plumbers 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 /> El Disapproved Sanitary Permit F a Un,ludes Groundwater HE%— <br /> Issuing Ag t Igna re( tamps) <br /> A roved Surcharge fee)pp ❑Owner Given Initial Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> S110-6398111 05194) DISTRIBUTION: Original to county.One copy To: Safety&Buddi"s Dhuiion,Owner,Plumber <br />