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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 Count n <br /> than 8 12 x 11 inches in size. <br /> • See reverse side for instructions for completing this application State Sanitary Permit.NyTribe <br /> r <br /> The information you provide may be used by other government agency programs El Chat; iJJtjlrevision to previous(DBapplication <br /> I Privacy Law,s. 15.04(i)(m)I. <br /> State Plan I.D.Number ^ <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION F/J1 <br /> Pro ,ertyOwner ame / Property location <br /> /Z I�A X11 e- 1.S�,�J x&514 A)t,) 1/4,5 3 3 T Y Q ,N, R/ E(or) NO <br /> Property Owner's ailing Addres / Lot Number Block Number <br /> f? / C CJ, a, <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> o r LJ r o ( )x-7. -S�8// — <br /> II. TYPE F BUILDING: (check one) ❑ State Owned ❑ CiVilty Nearest Ro d <br /> Public 1 or 2 FamilyDwelling- No.of bedrooms ❑ Town OF�c �' <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) �j <br /> 1 ❑ Apartment/Condo � (s3 D 7� 3 / S �� 0 <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 online A. Check box on line B, if applicable) <br /> A) 1. ❑ New 2_ XReplacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.,❑ Repair of an <br /> __ System --------System ____ _ Tank Only ____ Existing S <br /> ____ gstem_yExisting 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 RSeepage Trench 22❑In-Ground Pressure 42❑Pit Privy <br /> 13❑Seepage Pit ���4T 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) Elevation <br /> / c2 S0 .17-0C) • '— 193- 5 Feet 57,5' / Feet <br /> VII. TANK Capac ty <br /> INFORMATION in gallons Total #of Manufacturer's Name Prefab. site fiber- Plastic Exper. <br /> New Existing Gallons Tanks concrete Con- Steel glass App <br /> strutted <br /> TTarnks Tanks �j <br /> Septic Tank or Holding Tank p oc) a (2!� S 1 fl-4� r_1 E] E] <br /> Lift Pump Tank/Siphon Chamber EJ El ❑ El 1:1 El <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) Pl umber's Signature No Stam s) MP/MPRSW No.: Business Phone Number: <br /> Plumber's Address(Street,City,State,Zip Code): <br /> ,Uor .s/s� s/'�e.� <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> E]Disapproved Sanitary Permit Fee Lndude5Groundwater ate IssuedIssuin A 'ntSi nature amps) <br /> 2n! E]E]Owner Given Initial urcharget. <br /> Adverse Determination O b�ay-gs <br /> X. CONDITION SOF APPROVAII)iii-/REASONS FOR DISAPPROV L: p <br /> bctcr I�/ STG�e tUr72�er— (!/7!` Yl4efl/ X �d U�roo/� <br /> 5HU-6398(R.05/94) DISTRIBUTION: Original to(ourd y.One copy To: Safety 8 Builldim js nivuion,Ovvner,VlemGxr <br />