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Safetyand Buildings Division <br /> SANITARY PERMIT APPLICATION Bureaof 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 /> • Atthch complete plans(to the county copy only)for the system,on paper not less County �9 <br /> than 8 112 x 11 inches in size. <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> The information you provide may be used by other government agency programs El Check it rev lR pleviuQus 6liion Q <br /> (Privacy Law,s. 15.04(1)(m))- cat <br /> State Plan I.D.Number S <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION I 97- /0 377 oc <br /> Property Owner Nam Property Location <br /> e.✓1n Kiri. afLK 1/4 1/4,5 /o T �3`l ,N, R/k/ Btcff>).W <br /> Property Owner' ailingA-dr s Lot Number / Block Number <br /> —?G O fi C G 17f Al <br /> City,State Zi CodePhone Number Subdivision Name or CSM Number <br /> s o ( 7161,6035-_ 6a 'R e4a <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ city Nearest Road <br /> Public 1 or 2 Famil Dwellin - No.of bedrooms Lj rowan OF klatzx C <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo 10az/-3//6- oZ.S>oU <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_ E] Reconnection of 5. E] 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 xSeepage 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 13- Absorp.Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade <br /> Required(sq.ft.) Prop sed (sq.ft.) (Gals/day/sq. ft.) (Min./inch) Elevation <br /> 30� 3Z 7 /Y/o� 97•o Feet 9 Feet <br /> VII. TANK Capacity <br /> in gallons Total #of Prefab. Site Fiber- Ex er <br /> INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel Plastic p <br /> New Existingstructed glass App. <br /> Tanks Tanks � ,� <br /> Septic Tank r,.Hol.`�',.r- 7S0 1 7So <br /> Lift Pump Tank eo SOO 0 ❑ Q 0 <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersignelMaB Xie responsibility for instal tion of the onsite sewage system shown on the attached plans. <br /> Plumber's <br /> b Signat :(No Stamps) rW1MPRSW No.: Business Phone Number: <br /> NW8 Coun Line Rd. �2ANAAARIF <br /> Plumber's Address tt p Code): <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (includes Groundwater ate Issue Issuing Ag tSigna ure( 5 mps) <br /> A roved C Surcharge lee) <br /> PP ❑Adverse Determination <br /> al /J� Q- 1d �5 <br /> Adverse Determination - <br /> X, CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SRU-63gR(R.05/94) DISTRIBUTION: original to(nuoiy.one copy To: Sarety d Ruild ings Dmm.ion,owner,Pl.,.W, <br />