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SANITARY PERMIT APPLICATION BureauSafeaofBuildinBildig Waterion Systems <br /> In accord with ILHR 83 05,Wis.Adm.Code 201 E.Washington Ave. <br /> P.O.Box 7969 <br /> Madison,WI 53707-7969 <br /> • Attach Complete plans(tothe county copy only)for the system,on paper not less County <br /> than 8 12 x 11 inches in size. <br /> 0 See reverse side for instructions for completing this application State Sanitary Permit Number iVf' <br /> The information you provide may be used by other government agency programs <br /> [Privacy Law,s. 15.04(1)(m)f. ❑Check r nY prwrous apphcauun <br /> State Plan I.D.Nu <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Name ro erty L cation <br /> /4,5 3 T N, R E(or( <br /> Prope Owner's Mailing Address Lot umber / Block Number <br /> Cit ,Sate SZl Code jPhnreNlLmber Subdivision Name or M Number <br /> I it. 7 ;, ___B_ 1141"5 <br /> II. TYPE OF ILDING: (check one) ❑ State Owned ❑ city Nearest Road <br /> Public 0 1 or 2 Family Dwelling- No. of bedrooms 3 ❑ ND valage A-KC-I 4 G f�BfS <br /> Town oFOLO <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 E] Apartment/ AZO '1_3 OZ (Ob <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 S stem 2- X Replacement 3. E] Replacementof q ❑ Reconnection of 5_ E] Repair of an <br /> y _________Ystem -____-_______ Tank Only __ Existing5ystem _ Exlsting5ystem <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 /> 1110 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. 7. Final Grade <br /> Required (sq. ft.) Pro osed(sq.ft.) (Gals/day/sq. ft.) (Min./inch) Elevation <br /> 3 o 1ll aa <br /> Feet <br /> D•S Feet <br /> VII. TANK Capacity <br /> -1 $ <br /> INFORMATION in gallons Total #of Prefab. Site Fiber- Exper <br /> New Existin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks / strutted <br /> Septic Tank or Holding Tank 'LOO ZOO W C <br /> Lift Pump Tank/Siphon Chamber El E] ElVIII. RESPONSIBILITY STATEMENT <br /> El <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:(NOS mps) MP/MPRSWNo.: Business Phone Number: <br /> oP s ul 3`FZ� 7lS 86�- /S7 <br /> Plumber's Address(Street,City State,Zip Code). <br /> Z n w 3S 06:9S1 WI• Stif893 <br /> IX. COUNTY/DEPART ENT USE ONLY <br /> El Disapproved Sanitary Permit Fee (IndudesGroundwater Date uefi issuing,;nt gn (No ps) <br /> $Approved E]Owner Given Initial 156- <br /> d c, Surcharge fee) � <br /> Adverse Determination27 <br /> X. CONDITIONS OF APPROVAL/REASONS F DISAPPROVAL: <br /> S8D-6398(R.05/94) DISTRIBUTION: Original to County,One copy To: Safety 8 Buildings Division,Owner,Plumber <br />