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t Safety and Buildings Division <br /> Vsligonsin <br /> SANITARY PERMIT APPLICATION POByy302ngtonAvenue <br /> In accord with ILHR 83.05,Wis.Adm.Code Madison,WI 53707-7302 <br /> O¢partm¢n[of Commarc¢ <br /> Attach complete plans(to the county copy only)for the system,on paper not less t5tate <br /> than 8 tie x 11 inches in size. <br /> • See reverse side for instructions for completing this application ENumbi4r <br /> Personal information you provide may be used for secondary purposes ation <br /> [Privacy Law,s. 15.04(1)(m)]- I.D. zj, <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION trr�l/ <br /> Propertcaner Name _. Property Location� w4 9 T40 ,N, R 5 E(or� <br /> Prope y Owner's Mailing Address Lot Numb br�Dv��'' L E <br /> 411 O. T <br /> Call,State Zip Code Phone Number Subdivision Name or CSM Number <br /> S4 3 ( IS> -'85 <br /> II. PE ILD NG: (check one) ❑ State Owned o Lilly Nearest RoadC] Village <br /> a�� <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms Town of 5 <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> ©lam--`1,Z O( goo <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. Ig New 2. ❑ Replacement 3_ ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> ___System ________Sy!stem ------------- Tank Only ____________ Existing System ________ ExistingSystem <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 5. Perc. Rate 6. System Elev. 7. Final Grade <br /> Regt�ir��(sq.ft.) Prop sseedd(sq.ft.) (Gals;ay/sq.ft.) (Min./inch) Elevation <br /> 4 <br /> �e (p"T 0__ — C15 -4 Feet T7 .9 Feet <br /> VII. TANK Capacity Site <br /> in gallons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic App.INFORMATION New Existin Gallons Tanks Concrete strutted glass APPp <br /> Tanksl Tanks <br /> Septic Tank or Holding Tank f000 [oaoIM Q ❑ Ej 1:1Lift Pump Tank/Siphon Chamber w El 13 ❑ <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 Stff ps) MP/MPRSW No-: Business Phone Number: <br /> - o ds r �ZS"SS! !S- 846. 41SI <br /> PI ber's Address(Street,City,S ate,Zip Code): / <br /> 277 0 w 7w w Wt_ S4893 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disa roved Sanitary Permit Fee (Includes Groundwater 7atessue Issuing Agent Signature(No amps) <br /> ❑ ppSurchargeFee) [yproved ❑OwnerGivenInitial < Z�q$ <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR-DISAPPROVAL: <br /> SBD-6398(R.11197) DISTPoBUTION: Original to County.One copy To: Safety&Buildings Division,Owner,Plumber <br />