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Safety and Buildings Division <br /> �.p SANITARY PERMIT APPLICATION Bureau Building Water Systems <br /> 201 E.Waashington Ave. <br /> In accord with ILHR 83.05,Wis.Adm.Code P.O.Box 7969 <br /> Madison,Wl 53 07 7969 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County <br /> than 8 trz x 11 inches in size. <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> The information you provide may be used by other government agency programs ❑check if evision to Urevious application <br /> (Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Name Property Location <br /> 1/4 1/4,52_4 T D ,N, R IS E(or W <br /> Pro ert Own is Mailing A dress Lot Number $locater <br /> 34 ORKWAVS 12. L <br /> Cit ,State Zip odds Number Subdivision Name or CSM Number <br /> A Z A 2 [Phone ) P. .7 <br /> II. TYPE OF LDING: (check one) El State Owned city Nearest Road <br /> Village '{�t LL,, <br /> Public 1 or 2 FamilyDwelling- No.of bedrooms Town OF-UCI< 6 IL 12_ <br /> III. BUILDIN : (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo 1 <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. X 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 ®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 /> 1. Gallons Per Day 2. Absorp.Area 3. Absorp.Area 4. Loading Rate S.Perc. Rate 6. System Elev. 7. Final Grade <br /> Required (sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> 30 b , S 7. Feet o�.3 Feet <br /> VII. TANK Capacity Site <br /> in gallons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- plastic Exper <br /> INFORMATION New Existin Gallons Tanks Concrete strutted glass App. <br /> Tanks Tanks �^ <br /> Septic Tank or Holding Tank Goo o (__+_5'E El ❑ ❑ ❑ F1 Q <br /> lift Pump Tank/Siphon Chamber I I El ❑ El 0 ❑ 0 <br /> Vlll. 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) r:3 <br /> MPRSWNo.: Business Phone Number: <br /> I6H o fill q ZG /S- 9 41S7 <br /> Pt mber's Address(Street,City,Statp,ZipCode): <br /> 21 w 3S aa3me L.1I. 54893 <br /> X1 COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (includes Groundwaterate $sue Issuing A&nt Signature(No Stamps) <br /> Surcharge fee) � <br /> pproved E]Owner Given Initial I�- L / f � <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.05/94) DISTRIBUTION: Original to County.One copy To: Safety&Buildings Division,Owner,Plumber <br />