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rtµ 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 County ������T r <br /> than 8112 x 11 inches in size. <br /> • See reverse side for instructions for completing this application State Sanitary�I�� -NMI umNumbe,,' r <br /> �Jn <br /> The information you provide maybe used by other government agency programs � ` � ❑Check it reviaaan to previous application <br /> IPnvacy Laws- 15.04(1)(m)]. �JDly� State Plan LD.Number ' t <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION* / — 0R 6 7 7 <br /> Prope yOwner Name Property location p <br /> S. V. a 1/4 1/4,'S a 7 T 37 ,N, R/p Y(or)W <br /> Property Owner's Mailing Address Loth ber Block Number <br /> 3 s'/ <br /> �ty,state / Zi Code P ne Num her Subdivision NameorC 'f ber Bs -4 ,3 <br /> �w (3uach A o (�co>Ya 49s Q V�� / O <br /> II. TYPE OF BUILDING: (check one) E] State Ownedit� / NeaCe'st add> /Qd <br /> ❑ To age d <br /> Public 1 or 2 FamilyDwelling- No.of bedrooms Town of YA <br /> III. BUILDING USE: (If building type is public,check all thatapply) 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_ W New 2. ❑ Replacement 3. ❑ Replacement of q ❑ 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 K-]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 5. Perc. Rate 6. System Elev. 7. Final Grade <br /> Required (sq.ft.} Proposed(s . ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> 30 ,20 0C 'o/ d4G.0 Feet Feet <br /> Capa It <br /> VII. TANK in gallons Total #of Prefab. Site Fiber- Exper <br /> INFORMATION Gallons Tanks Man f c r' ame Concrete Con- Steel Plastic p <br /> New Existin strutted Blass App_ <br /> Tanks Tanks S7d <br /> Septic Tank or Holding Tank e K ® El E ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber'sf�ame:�S.P_int) P m er's Si natu :(No Sta ps) UIP/MPRSWN Business Phone Number: <br /> APT JwerfC Thow� � <br /> 3? P, /,f�-y>•Z -�73s"— <br /> Plumber's ddress(Street,City,State,Zip CodE Ill <br /> _ <br /> o .0 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> [3 Disapproved Sanitary Perm"Fee (Includes Groundwater ate slue Issuing Agent Signatur (N Stamps) <br /> Approved ❑Owner Given Initial ]�a 3 "has) s/ /a Q/ <br /> Adverse Determination l / It7 <br /> ONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(8.DS'"f DISTRIBUTION: Original to County,One copy To: Safety 8 Buildings Division,Owner,Plumber <br />