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11119111 Safety and Buildings Division <br /> MILWtzi 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 �8 �� <br /> than 8 12 x 11 inches in size. 4 y/,ti e- <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> 30 �&o(0 <br /> The information you provide may be used by other government agency programs E]Check if revis on to previous application <br /> (Privacy Law,s. 1504(1)(m)1. State Plan I.D.Num ey, <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION W <br /> Property Owner Name /-7ropert Location <br /> �� 1/4,S3S T3V ,N, R /t E(or <br /> P operty Owner's Mailing Address Lot Number Block Number <br /> City,State Zip Code Phone Number 5v4d""ton Name or CSM Number <br /> G-ro(Je. /y/.t1 53"Jr 1(6/.7 )5ya0- Y6 /&/-6— <br /> ll. TYPE OF BUILDING: (check one) ❑ State Owned ❑ city Nearest Road <br /> ❑ Village ` <br /> E] Public 1 or 2 FamilyDwelling- No.of bedrooms 2 Town OFI- To slit!sot_) <br /> Ill. BUILDING USE: (If building type is public,check allthatapply) Parcel Tax Number(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 on line B,if applicable) <br /> A) 1. ❑ New 2. KReplacement 3. ❑ Replacement of 4. ❑ Reconnection of 5_ ❑ Repair of an <br /> __ System System ______ Tank-Only------- Existing System ____ExistingSystem <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 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. Final Grade <br /> Required(sq. ft.) Pro osed(sq.ft-) (Gals/day/sq.ft.) IMin./inch) Elevation evation <br /> O O O O 9a 0 — j � Feet 9, a Feet <br /> Ca acit <br /> VII. TANK in Ballo 5 Total #of Prefab. Site Fiber- plastic Exper. <br /> INFORMATION New Existin Gallons Tanks Manufacturer's Name Concrete con- Steel glass App. <br /> strutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank %00 ❑ E] ❑ ❑ <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:(Print) Plumber's Signature:(No Stamps) MP/MPRSW No.: P _y <br /> usiness Phone Number: <br /> X3 6 Y9- >-.:2 J <br /> Plumber's Address(Street,City,State,Zip Code): <br /> AV- <br /> Alfe x s .,^ oc -L) �✓ <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (Includes Groundwaterate Is ued Issuing AgenPStgn ture( o a <br /> )ielpproved [-]Owner Given Initial /5Q d i / <br /> o Surchdt9e t ee) � c / _ <br /> Adverse Determination / aur_ <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> 5RD-b39B(R.05/94) DI SIRIBUTION. Original to county.One(upy To: Surety&Ruilrlings Division,Owner,Plumber <br />