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Safety and Buildings Division <br /> 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 53707-796 <br /> •' Attach complete plans(to the county copy only)for the system,on paper not less count r <br /> than 8 112 x 11 inches in size. v `i <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> The information you provide may be used b other government agency programs �' to�� <br /> y p y y g g y p g ❑Check if revision to previous application <br /> (Privacy Law,s. 15.04(1)(m)I. <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Name , Property Location c— <br /> Am S / A/4)1/4 N(— 1/4,S Z,2 T z16) ,N, R /,SE(ork N <br /> PropertyOwner's Mailing Address Lot Number Block Number <br /> City,State TZlP Code Phone Number Subdivision Name or CSM Number <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ CiNearestNearest Road <br /> T L <br /> Public 1 or 2 FamilyDwellingL] Vill-No.of bedrooms Town OF r/ f3C S,p� <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Numcbber(s) <br /> 1 E] Apartment/Condo a — / '� /1 <br /> a U l �0 <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. I&New 2. ❑ Replacement 3. ❑ Replacement of 4- ❑ 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 ❑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 /> Gr Req/uired(sq. ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Mindinch) / Elevation <br /> E1 zj 6 �� , �� /q,7, e FeetQ 0 Feet <br /> TANK capacct <br /> VII• INFORMATION in allo s Total #of Manufacturer's Name Prefab Con- Steel Fiber- Plastic Exper. <br /> New Existin Gallons Tanks Concrete strutted Blass App <br /> Tanks Tanks <br /> Septic Tank or Holding.Tank ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/SiphonChamber ❑ ❑ ❑ ❑ ❑ ❑ <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:((PPrint) Plumber's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> Plumber's Address(Street,City,State,Zip Code): <br /> .Ls'o X Sl S ' c._-' Sy. 7� <br /> IX. jCOUNTY/ DEPARTMENT USE ONLY <br /> E]Disapproved Samt ry Permit Fee (Includes Groundwater ate ssue ss ng gent ature(No Stamps) <br /> XApproved I �SurchargeFee) '��❑Owner Given Initial <br /> Adverse Determination <br /> X. rONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(H.05/94) DISTRIBUTION: Original to Counly.One copy To: Safety&Buildings Dimsion,Owner,Plumber <br />