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6 9 ` l/U/ Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION Bureau of Building Water Systems <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. 4in/1,Q <br /> • See reverse side for instructions for completing this application State Sanitary SPermi//�®�7 <br /> PermitNumber <br /> The information you provide maybe used by other government agency programs ❑Check it revision to previous application <br /> (Privacy Law,s. 15.04(1)(m)). <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Prope y Owner Name , Property Location <br /> ,ems 4 1/4,5 3-S7 T ("j ,N, R /rte E(or)® <br /> Property Owner's Mailing Address Lot Number Block Number <br /> r r L)e— U), ._ <br /> Ci ,State Zip Code Phone Number Subdivision Name or CSM Number / r <br /> oS e Ll, � /1�y11 3"�// 40,2 ) YY3-/I o y "'O/ f C 1 .5',4 e- .0 e, <br /> II. TYPE OF BUILDING: (che(k one) ❑ State Owned El CitIyy Nearest Road 2 7519 <br /> E] Public 1 or 2 FamilyDwelling- No. of bedrooms o Towan OF .4C/-s ani 4crr�- <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo <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_ Q 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 KSeepage Bed 21 []Mound 30❑Specify Type 41 ❑Holding Tank <br /> 12❑Seepage Trench 22❑ In-Ground Pressure 42 Q 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 /> DO a q 3a 7 1 194, 1 Feet t/8- 3` Feet <br /> Capacity <br /> VII. TANK in gallons TOtal #of Prefab. Site Fiber- plastic Exper. <br /> INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- steel lass App- <br /> New <br /> Existingstrutted g <br /> Tanks Tanks <br /> Septi:Tank or Holding Tank FOO S �¢�� �. ❑ ❑ El ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ El <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the underS' ned,assume responsibility for installation of the onsite sewage system shown on the attached plans- <br /> S)Plumber'sSignature:(NoStamps) MP/MPRSWNo.: Business Phone Number: <br /> Plumber's Address(Street,City,State,Zip Code): <br /> -&>< %` _.5/;--C�7.-- J L.J SSB 2 <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fe (Includes Groundwater FatqlssucdIssuing Age ignature(N amps) <br /> roved surcharge Fee) <br /> pp ❑Owner Given Initial <br /> Adverse Determination /�� <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SHO b398(R.W94) DISTRIBUTION: Original to county.One espy To: Safety&Ruildings Division,Owner,Piumber <br />