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�1 CtM <br /> Safety and Building (vision <br /> G �IR SANITARY PERMIT APPLICATION Bureau of Building Water Systems <br /> In accord with(LHR 83 05,Wis.Adm.Code 201 E.Washington Ave.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 <br /> than 8 112 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 it revision ttopr viintt q an lication <br /> (Privacy Law,s- 15.04(1)(m)]. <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION- PLEASE PRINT ALL INFORMATION I <br /> Property OwnerName Property Location <br /> W/ F 7¢rU' S C-r/4 /L/6'1/4,S !j T j ,N, R �E(or(� <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 3o Srn , 3-!' .S7�_ — <br /> City,State Zip Code // Phone Number Subdivision Name or CSM Number <br /> II. TYPE OF BUILDING: (check one) E] State Owned ❑ It( r A Nearest Road <br /> Public 1 or 2 FamilyDwelling- No.of bedrooms L3 Town OF//r <:.C, rLJ „r�)°' <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo /6" 3 Y05- — 0 /00 <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 p 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- pKNew 2. ❑ Replacement 3_ ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> -----_System --------System ----- ----- Tank Only Existing System <br /> ----------------------------- 9 - -------------Exlsttng 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 /> 11I�{I Seepage Bed 21 E]Mound 30 E]Specify Type 41 E]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 3771 2. Absorp.Area 3. Absorp.Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade <br /> Required (sq. ft.) Pro/posed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elev do <br /> -5 Feet �0�Feet <br /> VII. TANK Capacity <br /> INFORMATION in gallons Total #of Manufacturer's Name Prefab Site Fiber- Exper <br /> New ExistingGallons Tanks Concrete Con- Steel glass Plastic App <br /> strutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank 000 /Q()o El EJ El10 <br /> LiftPump Tank/Siphon Chamber � � ❑ ❑ El ❑ <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 /> Plumber's Address(Street,City,State,Zip Code): <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanit ry Permit Fee (includes Groundwater ate s e Issuing Age Sign ture(No to ps) <br /> Approved ❑Owner Given Initial Surcharge Fee) C!yy <br /> ( Adverse Determination �Q <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.05194) DISTRIBUTION: Original to Counly.one copy To: Safety&Buildings Division.Owner,Plumber <br />