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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,WI 53707-7969 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County <br /> than 8 112 x 11 inches in size. Q <br /> • See reverse side for instructions for completing this application S ate Sanitary PPeluniit Number <br /> The information you provide may be used by other government agency programs E]Check 7revision to previous application <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number �� <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION �(� <br /> Property Owner Name Prope ocation <br /> 'BILLI p-r 1/4 1/4,S T Lfo ,N, R 1� E(or)(9 <br /> Property Owner's Mailing Address Lot Nu Ker Block Number <br /> 6 SS NAM L.Er AV tJ. <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> R L 6 Mtj. —CL52Q (6,12)770-398 1— 13 fl. n3 <br /> II. TYPE OFBUILDING: (check one) ❑ State Owned L] City Nearest Road <br /> e ag <br /> Public 1 or 2 FamilyDwelling3 ❑- No.of bedrooms Vil own of Er(C}} <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo QZQ q,�08 of Z10 <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. ® 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 /> 1 1 ®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 15. Perc. Rate 16. System Elev. Final Grade <br /> Required(sq. ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation evation <br /> 450 � q3 6qS 9s 9 Feet �g•'f Feet <br /> Capacity <br /> VII. INFORMATION in gallons Total #of Manufacturer's Name Prefab. Site Con- Steel Fiber- Plastic Exper. <br /> New Existin Gallons Tanks concrete glass App. <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank QQQ 1000 1 S{,AW ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ <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:(Print) Plumber's Signature:(No tamps) MP/MPRSW No.: Business Phone Number: <br /> IC oAkjPJs t (.uwd 31n S- sr.6 IS? <br /> PI mber's Address(Street,City,State,Zip Code): <br /> 7..'1 (on pw 3S WtEsr'ER W1 , 4895 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> E]Disapproved Sanitary Permit Fee (incwdesGrovnd-aw, ate Issued Issuing A en ignatur N tamps) <br /> (;Approved 171 Owner Given Initial /��i� argeree) S o <br /> �1 Adverse Determination ( V <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R 0"4) DISTRIBUTION: Original to Counly,One copy To: Safety&Buildings Division.Owner,Plumber <br />