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Safety and Buildings Division <br /> r:�itL r�r� SANITARY PERMIT APPLICATION Bureau of Building Water Systems <br /> In accord with ILHR 83.05,Wis.Adm.Code 201 E.Washington Ave. <br /> 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. I rn X3-3 <br /> • See reverse side for instructions for completing this application State Sanitary PermitNumber �PC� <br /> The information you provide may be used by other government agency programsS <br /> ❑Chec d revision to previous-application <br /> (Privacy Law,s. 15.04(1)(m)I. State Plan LD_Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFOR ATION <br /> Property Owner Nme Propert,yy Location <br /> RL a v►Sa� sr- 1i4 (!E 1/4,5 03 T 31 N, R 14 E(or we O <br /> Property Owners Mailing A s Lot Number Block Number <br /> 8 ,n <br /> City,State Zip Code Phone Number Subdjvi on Name or C M Number <br /> gQQoWdC 5 o ( > i ao ids a-F- 6<j ao teds <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ City Nearest Road <br /> it <br /> Public W 1 or 2 Family Dwelling-No.of bedrooms Z E] Village <br /> Town OFInbC47 <br /> III. BUILDING USE: (if buildingtypeispublk,checkallthatapply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo o7_4-sicca -d3 <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 F PERMIT: (CKFReplacement <br /> ck only one box on line A. Check box online B, if applicable) <br /> A) New 2. 3. ❑ Replacement of 4. ❑ Reconnection of 5. E] Repair of an <br /> ---- - <br /> System -- ystem -- - ----- 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,gseepage 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 PerDay 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 /> Z00 ZS 41-2-- -7 Mor 1, 93.1 Feet $, Feet <br /> VII. TANK Capacity <br /> INFORMATION in gallons Total #of Manufacturer's Name Prefab siteCon- Fiber- Plastic Exper. <br /> New Existin Gallons Tanks Concrete steel glass App. <br /> Tanks Tanks I <br /> strutted <br /> Septic Tank QLMaWooj-+vrrk-- O .4tr rroa / �$KiQe.� ® 1 ❑ 0 ❑ <br /> lift Pump Tank/Siphon Chamber E1 ❑ F1 Ej 1 171 El <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume respon bility for installation of the onsite sewage system shown on the attached plans- <br /> Plumber's N MEMOIL TESTING <br /> lans.Plumber'sNrM0ILTESTING lu er'sSi ture:(No Stamps) MP/ No.: BusinessPhone Number: <br /> Plumber's Adc1j6 rft S1g4W�Code): <br /> 715) 635-Z489 <br /> IX. COUNT�P// DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (lnduden Croundwater ate Issue Issu g gent Signature(No Stamps) <br /> Approved [-]Owner Given Initial �7D Surcharge Fee) <br /> Adverse Determination /TjI J <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SRU-6396(R.05/94) DISTRIBUTION: Original L)County.One copy To: Safety&Ruildinyn Division,owner,Pluntrer <br />