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/Gy1�� 1 <br /> Safety and Buildin s Division <br /> e:�■ter. SANITARY PERMIT APPLICATION Bureau of Building Water System-, <br /> In accord with ILHR 83.05,Wis.Adm Code 201 E.Washington Ave. <br /> • P.0 Box 7969 <br /> Madison,WI 53707-7969 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less CountyI y� <br /> than 81/2 x 11 inches in size. U 1 <br /> • See reverse side for instructions for completing this application State Sanitary P r it Nu ber <br /> The information you provide may be used by other government agency programs `� Y— C <br /> (Privacy Law,s. 15.04(1)(m)]. <br /> ❑Check if revision to previous application <br /> State Plan I.Q,„N ( er 9 <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION GJ <br /> Property Owner Name �' 1 Property Location <br /> E W k, -_ 1/4 1/4,5 $ T N, R l$ E(or� <br /> Prope yOwner'sMailingAddress Lot Number B1eek-Pon fiber <br /> 1095- Co , RD - A RGRES <br /> City,S to Zip Code iPhneNumber Subdivision Name or CSM Number <br /> I. > <br /> II. TYPE F BUILDING: (check one) ❑ State Owned. ❑ City Nearest Road <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms 3 [3 village M 7�`I <br /> Town OF W�f``V FV- 'p <br /> III. BUILDING USE: (If building type is public,check afthat apply) Parcel Tax <br /> �Number(s) { <br /> 1 ❑ Apartment/Condo X702 — _ 0a IF/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 0 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-jK 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 E]Specify Type 41 Holding Tank <br /> 12 E]Seepage Trench 22�In-Ground Pressure 42❑Pit Privy <br /> 13 0 Seepage Pit 43❑Vault Privy <br /> 14 0 System-In-Fil l <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 /> 1-150 1Required (sq. ft.) Proposed�qoo (sq.ft.) (Gals/day/sq. ft.) (Mi ) (}��jJ. Elevation <br /> -�Z•0 Feet 96, 3 Feet <br /> VII. TANK iCapacity <br /> g Ions Total #of site <br /> INFORMATION Gallons Tanks Manufacturer's Name Prefab- Con- Fiber- plastic Exper_ <br /> New Existin Concrete strutted Steel glass App <br /> Tanks Tanks <br /> Septic Tank or Holding Tankwe <br /> Lift Pump Tank/Siphon Chamber 1:1 ❑ E] ❑ ❑ <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:(Pri&XIds <br /> PlumbeisSignature:(N amps) MP/MPRSWNo.: Business Phone Num ber: <br /> 3�zb S- - yis <br /> PI tuber's Address(5 reet,City,Sta e,Zip Code). <br /> w I E2 If W11. 54893 <br /> IX. COUNTY/DEPARTME T USE ONLY <br /> ❑Disapproved Sanita yPermit Fee (Includes Groundwater D <br /> ateIssuing g nt5i ture amps) <br /> Approved Owner Given In ch.rgeree)❑ �Adverse Determination l ti( <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.05/94) DISTRIBUTION: Original to County,one copy To: Safety 8 Ruildings Division,Owner,Plumber <br />