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ale <br /> SANITARY PERMIT APPLICATION Bureauaofeuilding 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 Count <br /> than 8 112 x 11 inches in size- <br /> • See reverse side for instructions for completing this application State Sanitary <br /> yPPermit Number <br /> The information you provide may be used by other government agency gr ❑Check it—re sisioo t Pre is application <br /> [Privacy Law,s- 15.04(1)(m)]. <br /> g:::;r+p Hyl State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRIN LL INF <br /> Prop rt Owner Name Property Location <br /> 1e ; r�7� T L�j N, R �l� F„(!�r)W <br /> Property Owner'sMailingAddress Lo um+b�er Block Number <br /> C*St O . Zi Code Phone Number S bdivis o a or CS Number — <br /> 06 6 � <br /> IE OF BUILDING: (check one) ❑ State Owned ❑ City Near t Road <br /> /rjt ��� �C <br /> Public 1 or 2 FamilyDwelling ❑ Village-No.of bedrooms rows of G-O <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s))1 � p <br /> 1 E] Apartment/Condo ©�9 ^ `T/ � —0 s T Qp <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 <br /> 13 E] Other: specify <br /> IV. TYPE OF PERMIT: (Check only one box online A. Check box on line B,if applicable) <br /> A) 1. New 2. ❑ Replacement 3. Re lacement of <br /> ❑ p 4. ❑ Reconnection of 5. E] Repair of an <br /> ____ yS-stem _- ___System - --- - TankOnly---- ---- 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 /> 7. Gallons Per Day 2. Absorp.Area 3. Absorp.Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade <br /> 30 <br /> 0 <br /> Required(sq. ft.) Proposed(sq.ft.) (Gals/da /sq.ft.) (Min./inch) Elevation 9� <br /> 175 577002• 95,;Z Feet 7Z. Fee <br /> VII. TANK Capacity <br /> INFORMATION in gallons Total #of Manufacturer's Name Prefab Site Fiber- Exper <br /> New Existin Gallons Tanks Concrete Con- steel glass Plastic App <br /> Tanks Tanks structed <br /> Septic Tank or Holding Tank A?50 n r-1 ❑ Ei <br /> Lift Pump Tank/Siphon Chamber El Ej Ej I Q ❑ <br /> VIII. RESPONSIBILITY S ATEMENT <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 - nature:(No to ) MP/MPRSW No.: Business Phone Number: <br /> PRJ r's Ad ess(Street,Ci y, tate,Zip Co <br /> D L L CF <br /> 1 . COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (includes Groundwater ate ssue Issuif1�g/,Agent Signature(No Stamps) <br /> A roved Surcharge tee) 7�aU r-: <br /> Pp ❑Owner Given Initial I <br /> Adverse Determination I✓7r�- , o�OD <br /> NDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.05/94) DISTRIBUTION: Original to County.One copy To: Safety&Buildings Division,Owner,Plumber <br />