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/ _ r <br /> Safety and Buildings Division <br /> E <br /> 7iR SANITARY PERMIT APPLICATI N � 1�'1 Bureau of Building Water Systems <br /> / 201 E.Washington Ave <br /> In accord with ILHR 83 05,Wls-Adm.Code P.O.Box 7969 <br /> Madiso WI 53707-7969 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County /7 <br /> than 812 x 11 inches in size. d-"u '/3 <br /> • See reverse side for instructions for completing this application State Sanitary Per tNum Der <br /> 5 <br /> The information you provide may be used by other government agency programs ❑Check n revision to previous application <br /> (Privacy Law,s. 15.04(1)(m)1. <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> PropeLty OwnerNa Property Location <br /> IjIA.) Ne 1145,' 1/4,56 T� ,N, R/6 E(org <br /> Property Owner's Mailing Address Lot Number Block Number <br /> City,StateZip Code Phone Number Subdivision Name or CSM Number <br /> /„J s- 830 <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned 0 City Nearest Road <br /> ❑ Village u%7SS O�ac.k aelir'T/v, <br /> Public 1 or 2 FamilyDwelling- No. of bedrooms Z own OF S <br /> III. BUILDINGUSE: (If building type is public,check all that apply) Parcel TaxNumber(s) J /y�y� ,� <br /> 1 71 Apartment/Condo 6 3)-- ?b!0 ' Qm1 ft <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. E] Replacement of 4 E] Reconnection of 5 E] Repair of an <br /> ------System System - Tank Only --- Existing System Existing System <br /> B) ❑ ASanitary 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 J;A 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 5. Perc. Rate 6. System Elev. 7. Final Grade <br /> Required (sq. ft.) Proposed(sq. ft.) (Gals/day/sq. ft.) (Min./inch) 7 Elevation <br /> f5 0 % — 9.s_, / Feet 79, Ir Feet <br /> VII. TANK Capacity <br /> in gallons Total #of Prefab Site Fiber- Plastic Exper <br /> INFORMATION Gallons Tanks Manufacturer's Name Con- Steel <br /> New Existing Concrete strutted glass <br /> App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank 0 0 JAO / �/�p.,�„� 0-. El I El 1 1:1 0 <br /> Lift Pump Tank/Siphon Chamber El I El 1 1:1 1--] 0 <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 Stamp ) MP/MPRSW No.: Business Phone Number <br /> Plum,�bpper's Address(Street,City,State,Zip Code): <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> E]Disapproved Sanitary Permit Fee ^,wde,crovndwacer ate Issue Issuing Agent Sl ature No Sta <br /> J-; proved ❑Owner Given Initial 9e reel ^ /� <br /> Adverse Determination e>ei� !JG/// P <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> S1306398(a.05/94) DISTRIBUTION. O...... l o>Couoty,One appy Tm Sulety 8 Puildin9a pivoion.Owneq Plumnar <br />