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S Dar <br /> E <br /> triR SANITARY PERMIT APPLICATION BueauofBuilin Division <br /> Bureau of Building Water Systems <br /> 201 E.Washington Ave. <br /> In accord with LH R 83 05,W is-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 mot less County / �© <br /> than 8 112 x 11 inches in size. 16 yy" .0 e_ <br /> • See reverseside for instructionsfor completing thisapplication State Sanitary Permit Number <br /> c-�2569. o <br /> The information you provide maybe used by other government agency programsS <br /> G E]Check d revision to previous application <br /> IPrivacy Law,s. 15.04(1)(m)I- a <br /> el State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Name Property Location �- <br /> 2¢r .To Q / .er f}.n-.3 5,F 1/4 c_ 1/4,59.8 Thy ,N, R /6 E(or)(g <br /> Property Ownerf Mailing Address Lot Numbr Block Number <br /> So D LAKe Vi is 1fd, — <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> S yre� G✓� s-y�7a ( )3Y9-7,284 ---- <br /> II. TYPE OF B ILDING: (check one) ❑ State Owned [] Cit�age <br /> Nearest Road 7 <br /> Ao <br /> Public 1or2Famil Dwelling [3 vii- No.ofbedrooms Town CIF an) /J7, ✓lowu 1\J <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> a S - 33-2 "�' 3 a7'try-+� ho - Sro Ac✓'es <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. jZ New 2. ❑ Replacement 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 D9 Seepage Bed 21 ❑Mound 3 0❑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 Rat 5. Perc. Rate 6. System Elev. 7. Final Grade <br /> JF Ys Required (sq. ft.) Proposed(sq.ft.) (Gals/day/Sq <br /> Gal/day/sq.ft) (Min./inch) p/ Elevation <br /> "" ! 5 � 6yg y /( Feet 7 Feet <br /> Ca aclt <br /> VII. TANK ngallons Total #of Prefab. Site fiber- Ex er <br /> INFORMATION Gallons Tanks Manufacturer' Name Concrete con- Steel glass Plastic xpe <br /> New ExistIn strutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank 1/0001 ® ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber I ❑ I ❑ ❑ 1 ❑ ❑ 1 ❑ <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/v1PRSW No.: Business Phone Number: <br /> 6_7 � R afs lib/i.1 <br /> Plumber's Address(Street,City,Sta)e,Zip Code): <br /> t3ak S/ _$� re.v <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit F e Ilndudes Groundwater Date Issued Issuing Ag t S!PrtAur tamps) <br /> roved Surcharge Fee) I / <br /> pp ❑Owner Givenlnitial L& <br /> Adverse Determination — <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SOD639Bpt 05N34) DISTRIBUTION: Original to county,One copy To: Safety B B aldings Division,owner,Plumber <br />