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Safety and Buildings Division <br /> i:.iL'■:; 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 53707-7969 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County ��/ <br /> than 8 1/2 x 11 inches in size. <br /> 53 <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> a's 717 <br /> The information you provide may be used by other government agency programs ❑Check if revision to previous application <br /> tPrivacy Law,s. 15.04(1)(m)]. State Plan I.D.Num�y ,t <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION NA— <br /> Property Owner Name Property Location <br /> 1/4 1/4,S T qP <br /> ,IN, R E(or)9 <br /> Prop y wner's Mailing Address Lot Number 61ertk P}ymbeT W <br /> Z us <br /> City,State Zi Code Phone Number Subdivision Name or CSM Number <br /> (1e ((P M)US3 Z <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned o ity �j Nearest Road <br /> ❑ village f+ N C6 . RQ_ C <br /> Public 1 or 2 FamilyDwelling- No.of bedrooms Z Town DF <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo <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 online B,if applicable) <br /> A) 1. ❑ New 2. DoReplacement 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 /> 11 gSeepage 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 S. Perc. Rate 6. System Elev. 7. Final Grade <br /> Re ired(sq. ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min-/inch) Elevation <br /> —300Z b ""�� 93. 3 Feet 5-g Feet <br /> TANK Capact <br /> VII. FORMATION in allons Total #of Manufacturer's Name Prefab Con- Steel Fiber- Plastic Exper <br /> Site New Existing Gallons Tanks concrete strutted glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank ❑ ❑ ❑ ❑ ❑ <br /> lift Pump Tank/Siphon Chamber �rj „$DD 4;1 3" ❑ ❑ ❑ ❑ ❑ <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' Signature: No amps) MP/MPRSW No.: Business Phone Number: <br /> 91 C 14#4RO o 7� , - S7 <br /> Pitimber's Address(Street,City,State,Z"C od <br /> 0 35 GtI1. .3 3 <br /> IX. COU TY/ DEPARTMENT USE)ONLY <br /> ❑Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Is ng1X9ent Si re(No Stamps) <br /> A roved Surcharge Fee) <br /> pp <br /> [:]Owner Given Initial ' <br /> Adverse Determination / i6 <br /> ONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.05/94) DISTRIBUTION: Original to County,One copy To: Safety 6 Buildings Diwoon,Owner,Plumber <br />