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Safety anc�� <br /> d Buildings Division <br /> Bureau of Building Water System' <br /> :.+ SANITARY PERMIT APPLICATION 201 F.Washington Ave. <br /> rC�nn . <br /> In accord with(LHR 83.05,Wis.Adm.Code P.OBox 7969 <br /> Madison,Wl 53707-7969 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County 26 , <br /> µ <br /> than 81/2 x 11 inches in size. StateSanitary Perm <br /> • See reverse side for instructions for completing this application CCCCIQIIIII�� �� <br /> The information you provide may be used by other government agency programs E]Check it revision to previous application <br /> (Privacy Law,s. 15.04(1)(m)I. State Plan I.D.Number O <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMProperty ATIONocation ( T NR E(or W (�1 <br /> Property Owner Name 1/4 1/4,S , \I / <br /> Lot N u m be r g♦�IrMy�ieF YYY <br /> Propert Owner's M Ili g ddre s L <br /> City,State O Zip Code Phone Number Subdivision Name or CSM Numbe: I <br /> Nearest Road <br /> II. TYPE F BUILDING: (check one) ❑ State Owned 3 o visage ^ �. 00 E 2 <br /> Public 1 or 2 Famil Dwellin -No.of bedrooms To F <br /> par el TaONumb`eOr(5) <br /> III. BUILDING USE: (If building type is public,check all that apply) <br /> OZ� Ott! 0 b <br /> 1 ❑ Apartment/Condo 10 ❑ Outdoor Recreational Facility <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 11 ❑ Restaurant/Bar/Dining <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 12 ❑ Service Station/Car Wash <br /> 4 ❑ Church/School 8 ❑ Mobile Home Park <br /> 13 E] Other: specify <br /> 5 ❑ Hotel/Motel 9 E] office/Factory <br /> IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B,if applicable) <br /> )nection of 5. ❑ Repair of an <br /> Replacement 3- ❑ Replacement of 4. ❑ Existin S stem Existin System <br /> New 2. JK p Tank -----g-y---- <br /> S stem --------Y-------------------g-y------------- <br /> p) 1' y _ _ System _____---____ Date Issued <br /> g) ❑ A Sanitary Permit was previously issued. Permit Number <br /> V. TYPE OF SYSTEM: (Check only one) Other <br /> Pressurized Distribution Experimental <br /> Non-Pressurized Distribution 21 30❑ p yype S ecif T 41 E]Holding Tank <br /> 11 Seepage Bed ❑Mound 42❑Pit Privy <br /> � <br /> 12❑Seepage Trench 22❑In-Ground Pressure 43❑Vault Privy <br /> 13❑Seepage Pit <br /> 14❑System-In-Fill <br /> VI. ABSRPT <br /> OION SYSTEM INFORMATION: Final7. rade <br /> 1.Gallons Per Day 2. Absorp.Area 3- Absorp.Area 4. Loading Rate 5. Perc. Rate 6. System Elev. Elevation <br /> Req it d (sq.ft-) Proposed3(sq.ft.) (Gals/day/sq.ft.) (�2nch)-' 9L4-7 Feet L- Feet <br /> 3 <br /> Capacity Prefab Site Fiber- plastic Exper. <br /> VII. TANK in allons Total #of Manufacturers Name con- steel lass APP <br /> INFORMATION New Existin Gallons Tanks concrete structed g <br /> Tanks Tanks ❑ ❑ ❑ [] ❑ <br /> Septic Tank or Holding Tank VV ❑ ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage <br /> ew agesw Nom shown on�th the Phoned pubes <br /> Plumber's Name:(Print) Plumber" Signature(N tamps) Business <br /> 866 - <br /> PI mber"sAddrez ( reet,City,St te,ZipCode) <br /> : <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> Sanitar PermitFe.@ (in,ludesGroundwate( ate ssue Issuing Age t5ignature(N tamps) <br /> E]Disapproved y V6i�J Surcharge Fee) <br /> Approved ❑Owner Given Initial I�6 <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-63911(R.05/94) <br /> DISTRIBUTION: Original to counl y,One copy To: Satecy&BuilUingn Divrion,owner.Plumber <br />