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_ Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION Bureau of Building Water Systems <br /> 201 E.Washington Ave. <br /> In accord with ILHR 83 05,Wis.Adm.Code P.O.Box 7969 (\` <br /> Madison,W153707-7969 w <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County 1::520 <br /> than 81/2 x 11 inches in size. <br /> • See reverse side for instructions for completing this application State Sanit�aryyPPermit <br /> � ,Number <br /> The information you provide may be used by other government agency programs ❑check if revlsio©pre vlous p�ca,on <br /> [Privacy Law,s. 15.04(1)(m)]. <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION _?,,7—,QQZ9T 46- <br /> Propert Owner Name Property Location <br /> F1 ME:� 139OWN NW <br /> 1/4 CJ 1/4,S 20 T 37 ,N, R r 8 E(or& <br /> Propert Owner's Mailing Address Lot Number r <br /> A/ 2 6L. <br /> City,State I Zip Code Phone Number Subdivl on Name or CSM N ber <br /> R STH L 1(612_)_531-S110 T IS P. <br /> II. T PE OF BUILDING: (check one) ❑ State Owned ❑ City Nearest Road <br /> Village �!n <br /> Public 1 or 2 FamilyDwelling- No. of bedrooms 3 Town OF RADE LK. 00,149 �- TGftQ. <br /> 111. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo I o34 /SZO a3 ozo <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-X New 2- ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5- ❑ Repair of an <br /> System 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 /> 11E]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 /> Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> NA Feet Feet <br /> Capacity <br /> VII. INFORMATION in gallons Total #of Manufacturer's Name Prefab Site Con- Steel Fiber- Plastic Exper <br /> New Existing Gallons Tanks Concrete strutted Blass App, <br /> Tanks Tanks �r <br /> Septic Tank or Holding Tank 2 OO �JOp 1 sfif� XSJ ❑ ❑ ❑ ❑ ❑ <br /> L ift Pum p Tank/Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ <br /> Vill. 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-( tamps) MP/MPRSW No.: Y21115-ggo- <br /> siness Phone Number: <br /> 9M-14P o P i� u�L�tid 3 0 7 <br /> Plumber's Address(Street,City,State, ip Code). <br /> 2'7 0 w 35 l kosr 5tz <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary,Permit Fee (includesGroundwater Agen gnatur 5 ps) <br /> pproved ❑Owner Given Initialurcharge Fee)etermination Tjart/e7;—u;7e/ ,,suing <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6396(R.05/94) DISTRIBUTION: Original to county.One copy To: Safety 6 Buildings Division,Owner,Plumber <br />