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Safety and Buildings Division <br /> �L R 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 53707-7969 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County p <br /> than 8 12 x 11 inches in size. z Z—,,u / <br /> • See reverse side for instructions for completing this application State Sanitary Permit Num*r <br /> X56 9f5 <br /> The information you provide may be used by other government agency programs ❑Check it revision to previous application <br /> lPrivacy Law,s- 15.04(1)(m)I. � <br /> State Plan.fjy�be' �6 -7/ G <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION `I <br /> Prop Owner Name Property Location <br /> SCF1/4 Str:- 1/4,S / T /_/0 ,N, R E(orl�/ <br /> Property Owner's Mailing�]Address , Lot Number Block Number <br /> City State Zip Code Phone Number Subdivision Name or CSM Number <br /> II. TYPE F BUILDING: (check one) E] State Owned ❑ lty Nearest Road <br /> ❑ Village C ,p <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms Town of cs# �U <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo <br /> 6 a 1- 4 /7 0 X00 <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.g Replacement 3_ ❑ Replacement of 4- ❑ Reconnection of 5_ ❑ Repair of an <br /> -----System --------System - - -- Tank Only-------------- Existing System ---------Existing System <br /> -------- ------ <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;A 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 /> X Y5 3` B " . C 7 9SI Feet /W- ?- Feet <br /> Ca aclt <br /> VII FORMATION in gallonSite <br /> s Total #of Manufacturer's Name Prefab- Con- glass Plastic aPPr <br /> New Existin Gallons Tanks Concrete strutted steel <br /> Tanks Tanks <br /> Septic Tank or Holding Tank 0670 ® ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber t4ov 1 600 L ❑ ❑ ❑ ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> 1,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 /> _7 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fein(in(wdeseroundwater Date Issue IssuingAg� natu ( Stamps) <br /> roved V urcharge Fee) <br /> App ❑Owner Given ,��� <br /> Adverse Determination /010 6 <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.05194) DISTRIBUTION: Original to County.One copy To: Safety B Buildings Division,Owner,Plumber <br />