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- a Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION Bureau of Building Water Systems <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 /l <br /> than 8 112 x 11 inches in size. 4 r N eo � <br /> • See reverse side for instructions for completing this application State Sanitar Permit Nu(`m(k� <br /> The information you provide may be used by other government agency programs ❑Check it> �n tOvialis aO©ppli tion <br /> (Privacy law,s. 15.04(1)(m)]. State Plan I -Number n <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION I o2,.3-> 7 `1Yi <br /> PK;y 0��ryrynerName v Property Location <br /> ^tl.l c-2 7 H� (JI/4 t,�f/4,S �(C, T 3 N, R <br /> Property Owner's Mailing Address Lot Number umber <br /> tO Block N <br /> O <br /> City,State I Zip Code Phone Number Subdivision Name or CSM Number 97 <br /> ar% 'K I1 S YH Sslb (s-o )zf,3_6q7 Gov, d-e <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ Cit ^tom Nearest Road <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms Ll VII(aeTown OF J/Q�l C' �S ✓ v4 140,% CV. T)r <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber((s) <br /> 1 F-1 Apartment/Condo 1006 1) Y/4=1 4� BOO <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_ ❑ Replacement of q ❑ 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 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 S. Perc. Rate 6. System Elev. 7. Final Grade <br /> q's Required (sq. ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> Feet feet <br /> Ca acit <br /> VII. TANK in gallo s Total #of Prefab. Site Fiber- plastic Fxper <br /> INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- steel glass App. <br /> New Existin strutted <br /> Tanks Tanks <br /> Septic Tan or Holding Tan ) Qp ! to e e,S-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) Plu ber'sSignatu :( Stamps) MP/MPRSW No.: Business Phone Number: <br /> 22522. 7/,S- <br /> P1 mbar's Address(Sire City,State,Zip Cod _4 01 �I <br /> 1/�\/ � <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved anitary Permit Fee lin(ludes ter ate ss e Issuing n atu ( Stamps) <br /> -Approved ❑Owner Given Initial / / d� Sur<narge Fee) !/3�! lc.O <br /> Adverse Determination ` / l <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD6398(It.05/94) DISTRIBUTION. Original to(nuo,One copy To. Safety 6 Ruilaings Divmmn,Owner,plumber <br />