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c / / <br /> Safety and Buildings Division <br /> �•�•ar• SANITARY PERMIT APPLICATION Bureau of Building Water System! <br /> In accord with[LHR 83 05,Wis.Adm.Code 201 E.Washington Ave.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 _2G /O <br /> than 8 t/z x 11 inches in size. <br /> • See reverse side for instructions for completing this application State Sanitary Permit Nugagev <br /> The information you provide may be used by other government agency programs ❑Check it revision to previous application <br /> [Privacy Law,s. 15.04(1)(m)I. State Plan I.D.Numb <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Name Property Location q, <br /> KAR 1/4 1/4,S ZO T41 ,N, R 15 E <br /> PropIrty Owners Mailing Address Lot Number <br /> o PC'I • I_. <br /> City,S ate Zip Code (lne N ber Subd vviision Name or CSM Number <br /> I"ATriz MK <br /> I. TYPE F BU DING: (check one) E] State Owned- ° vlage 4.� Nearest Road <br /> Public 1 or 2 FamilyDwelling- No. of bedrooms town of ISS �' $od <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 Apartment/Condo <br /> biz. 5;Z7-c;, os qod <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 2-1 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 /> 11 Meepage Bed 21 ❑Mound 30❑Specify Type 41 ❑Holding Tank <br /> 12U 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 /> l,T Required (sq.ft.) Proposed(sq.ft.) (Gals/day/sq. ft.) (Min./inch 43 q E evatiion <br /> .•V ((w (off Feet 5.7 Feet <br /> Ca acct <br /> VII. TANK in gallons Total #of Prefab. Site Fiber- plastic Exper <br /> INFORMATION New Existing Gallons Tanks Manufacturers Name Concrete Con- Steel glass App <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank 1000 1 V low 1 4 ❑ ❑ El <br /> Lift Pump Tank/Siphon Chamber, d El El El 0 <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's Signatur (N tamps) MP/MPRSW No.: Business Phone Number: <br /> L <br /> PI tuber's Address(S reet,City, te,Zip Code): <br /> 64 <br /> IX. COUNTY/ DEPARTMLINT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (In(1udesGrowdwate( ate IssueIssuing Ant Si atur Stamps) <br /> Approved ❑Owner Given Initial / O ) Surcharge Fee) 11,2161qd <br /> rjAdverse Determination l�N�� CY(/ <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398 R.W94) DISTRIBUTION: Original to County.One copy To: Safety&Buildings Divoion,Owner,Plumber <br />