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iiiimii• • Safety and Buildings Dl Ision <br /> �■`ri■. SANITARY PERMIT APPLICATION Bureau of Building Water System <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 <br /> than 8 112 x 11 inches in size. ;�O5 <br /> • See reverse side for instructions for completing this application state Sanitar Permit Num <br /> bber <br /> The information you provide may be used by other government agency programs ❑check,e n tdpreviuus a <br /> )— Nu <br /> application[Privacy Law,s. 15.04(1)(m)). I <br /> State Plan Lmffe <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION /U "�0 <br /> 2 <br /> 6303 <br /> Property Owner Name II Property Location <br /> n14 Ue_ /1 8 ! 1/4 1/4,S ,�9 T , ,N, R E(or)Wa <br /> Property Owner's Mailing Address Lot Number r <br /> i /� C. r/C �� / £o✓ L c <br /> City,State Lp Code Phone Number SNb�wSeemMame or CSM Number <br /> S�fu R e rr7�. 53 a ;L )f'y F�6�`1 Uo / <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ city Nearest Road <br /> Public 5d 1 or 2 Family Dwelling- No. of bedrooms Eg O Town OF /.4,,/e_ <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) q <br /> 1 ❑ Apartment/Condo 3y� �5��/ � <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restau nt/Bar/Dining <br /> 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Servicetation/Car Wash <br /> 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ElOther: peufy <br /> IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) <br /> A) 1. NNew 2 ❑ Replacement 3. ❑ Replacement of q E] Reconnectio of 5 E] Repair of an <br /> -__ ,stem 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 Z 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(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> d e- G' Feet Feet <br /> VII. TANKCapacity <br /> INFORMATION in gallons Total #of Manufacturer's Name Prefab S t Fiber- Plastic Exper <br /> New ExistingGallons Tanks concrete Co Steel glass App <br /> Tanks Tanks strut ed <br /> SapZw as ur Holding Tank oe�U OC,`� / -S ham. GF- ® 0El <br /> Lift Pump Tank/Siphon Chamber ❑ El El <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned, assume responsibility for installation of the onsite sewage system shown or the attached plans. <br /> Plumber's Name:(Print) Plumber's Signature (No Stamps MP/MPRSW No I usiness Phone Number: <br /> Plumber's Address(Street,City,State,Zip Code) <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> E]Disapproved Sanitary Permit Fee Undvde,Ground.M,, atelssue Issum A e Signa re( o mps) <br /> Surcharge fee) <br /> pproved ❑Owner Given Initial ion /�aAdverseDetermina � i <br /> O <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> WD-b39N(R.O5/94) DISTRIBUTION Original M(nuol,.On,-,u,Tor Surer,B Buildln,rliv.,I ,Owner,Vl..t , <br />