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Safety and Build <br /> Bureau of Building Water System- <br /> r^e•� �' SANITARY PERMIT APPLICATION 201 E.Washington Ave. <br /> In accord with[LHR 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 8112 x 11 inches in size. yt.e* 4- ! l p r7 6 /5 <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> .;2 rG 9Y�?_ <br /> The information you provide may be used by other government agency programs (]Check if revision to previous application <br /> [PrivacyLaw,s 15.04(i)(m)]. <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Pr perty Owner Name A ropert Location p <br /> Vt A 12 Q 4 [�, 91/4 g(, 1/4,S ( p T j�' .N, R <br /> Property Owner's Mailing A%ress �4 Lot Number Block Number <br /> _Trx[_ <br /> City,state Zip Code Phone Number Subdivision Name or CSM Number <br /> w . I` 134872 (71V 6??-W? <br /> I1. TYPE F BUILDING: (check one) ❑ State Owned ❑ ity NearestRoad I <br /> Village 'Z\�,Ni,p�S <br /> Public 1 or 2 FamilyDwelling- No. of bedrooms Town oFJ1J/ S{Tc �e b <br /> III. BUILDING USE: (If building type i5 public,check all that apply) Parcel TaxNumber(s) G /� <br /> 1 ❑ Apartment/Condo 6D 6 _a <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. X 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❑Specify Type 41X Holding Tank <br /> E]12 Seepage Trench 22[-]In-GroundPressure 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 /> i/�; Required(sq. ft.) Proposed(sq.ft.) (Gals/day/sq. ft.) (Min./inch) Elevation <br /> C/ Feet Feet <br /> Capgut <br /> VII. FORMATION n allons Total #of Manufacturer's Name Prefab Site Con- Steel Fiber- Plastic Expec <br /> New Existin Gallons Tanks concrete strutted glass App. <br /> Tanks Tanks <br /> Septic TankrHolding Tank ® ❑ ❑ ❑ ❑ ❑ <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:(Pint PI ber'S ignatu oStamps) MP/MPRSWNo.: Business Phone Number: <br /> (S O-e► K L 137 7113 R6-� fiO'Dr <br /> Plumber's Address(Street,City,S te,Zip Co e): <br /> OV W-e�O S�`� �I• CO r-� <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee 0naode,Gmundwater ate ue Issd nt Slgn tur (N to ps) <br /> rOVed ucharge tee) 7p�� �� '�%S%�C'�Ar�� <br /> App ❑Owner Given Initial ��Q j r l/ <br /> Adverse Determination 00 <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD 63981R 05N4) DISTRIBUTION: Original to County,G..<.,Y To: Sere,,B euild,,g Dim,w,Owner,Plumber <br />