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Safety and Buildings Division <br /> SANITARY PERMITAPPLICAT4&N 20`E.WfhingtonAve.ding Systems <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 count <br /> than 8112 x 11 inches in size. <br /> State Sanitary Permit No her <br /> • See reverse side for instructions for completing this application 40 <br /> The information you provide may be used by other government agency programs E]Check 1 revision to previous application <br /> (Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> 1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Na a t7Subdivision <br /> rty Location <br /> P Y I 1/4,S,p q T o ,N, R `/ E(or)�C <br /> Property ner's Mailing Address C /� r _ Bc2 7 lock Number <br /> G e r tl / //t3 /t J 1 c'�sCity,StateZip Code Phone Number Name or CSM Number <br /> ALI <br /> II. T PE F BUILDING: (check one) ❑ State Owned Nearest Road <br /> ❑ VII(ageEK <br /> Public 1 or 2 Family Dwelling-No.of bedrooms VTown <br /> III. BUILDING USE: (if buildingtypeispublic,checkallthatapply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 X Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining <br /> 4 ❑ Church/I School 8 E] MobileHomePark 12 ❑ Service Station/Car Wash <br /> 5 E] 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. ❑ New 2_ KReplacement 3_ El Replacementof 4. E] Reconnection of 5. E] Repair of an <br /> y <br /> S stem (" System - Tank Only ___ Existing System ______ Existing System <br /> --- ---------- <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 KSeepage 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 /> Re wired(sq.ft.) ro Posed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) 47 Elevation <br /> �S- ��/6 — /� `> Feet /O/ Feet <br /> VII. TANK CapautY site <br /> in gallons Total #of Manufacturer's Name Prefab Con_ Steel Fiber- Plastic Exper. <br /> INFORMATION New Existin Gallons Tanks concrete strutted glass APP <br /> Tanks Tanks _ ❑ <br /> El EJ 1 11 <br /> Septic Tank or Holding Tank �$i�� `/°�� -2 �� <br /> Lift Pump Tank/Siphon Chamber ;2.5-o <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 <br /> OName:(Printt) �— Plumber's Signature:(No Stamps) MP/MPRSWNo.: Business Phone N, <br /> r r/ <br /> el <br /> Plumber's Address(Street,City,State,Zip Code): <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary P it Fee,(includes Groundwater ate Issue Issuing Age S ature o <br /> E] pp / Lj� <br /> Surcharge Fee) ) <br /> 4Approved owner Given Initial e -771 <br /> F-1 (c� <br /> Adverse Determination <br /> CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> (R.05194) DISTRIBUTION: Original to County,one copy To: Safety 8 Buildings Division,Owner,Plumber <br />