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,...> b. Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION Bureau of Building Water Systems <br /> In accord with ILHR 83 05,Wis.Adm.Code 201 E.Washington Ave. <br /> P.O.Box 7969 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less Count Madlso ,WI 53707-7969 <br /> than 81/2 x 11 inches in size. <br /> • See reverse side for instructions for completing this application states n;a P �( <br /> The information you provide may be used by other government agency programs H/� <br /> [PrivacyLaw,s- 15.04(1)(m)]. ❑Check it revision to previous application - <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATIONState Plan I.D. u r <br /> Property Owner Name <br /> /+ t- Property Location � <br /> Property ner'S Mailing Address /^ 5c 114 rVW/4,S Al T,�l,� ,N, R jg E(or) 11/� <br /> Block Number <br /> Lot Number <br /> City,State Zip C de Phone Number Subdivision Name or CSM Number <br /> II. TYPE OF BUI DING: (check one) ❑ State Owned ❑ City Nearest Road <br /> Public 1 or 2 Famil Dwellin - No.of bedrooms ❑ village <br /> Town OF ate / � [,cj; 7 G <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> �l <br /> 1 ❑ Apartment/Condo " ✓1 � CJ <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 <br /> 4 E] Church/School 8 ❑ Mobile Home Park E] Restaurant Bar/Dining <br /> 12 E] Service Station/Car Wash <br /> 5 ❑ Hotel/Motel <br /> 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_ jg Replacement 3_ ❑ Replacement of q ❑ Reconnection of 5_ ❑ Repair of an <br /> System System Tank Only Existin S stem <br /> ------------------------------------------------------------------9-y------------ Existing System <br /> -------System 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 21,91VIound <br /> 12 El Seepage Trench 30 El Specify Type 41 E] Holding Tank <br /> 22❑In-Ground Pressure 42 E]Pit Privy <br /> 13 El Seepage Pit <br /> 14❑System-In-Fill 43❑Vault Privy <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 /> y�C ' Required (sq. ft.) Proposed(sq.ft.) (Gals/day/sq. ft.) (Min./inch) Elevation <br /> 9� Feet d0- / Feet <br /> VII. TANK Capacity <br /> INFORMATION in gallons Total #of Prefab Site <br /> Gallons Tanks Manufacturer's Name Con- Faber- Plastic Exper <br /> New Existin Concrete Steel glass App. <br /> Tanks Tanks structed <br /> Septic Tank or Holding Tank l'ppv / S ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber k,;%)C3 I ❑ ❑ ❑ ❑ ❑ <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 Signature: No Stamps) MP/MPRSW No.: Business Phone Number: <br /> 77 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> Q� X r-�� <br /> X. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee &dudeseroundwater ate sue ssuingA n Signa re t mps) <br /> Approved E]Owner Given Initial ,, surcharge Fee) D <br /> <k <br /> Adverse Determination c-,2z-c / <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SND-6398(H.05/94) DISTRIBUTION: Original to County.One Copy To: Safety&Builainyi Division,Owner,PiumWr <br />