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11t�iSC'o�s��rt �tcrtol( `� di <br /> Safety and Buildings Division <br /> 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 I Q C <br /> than 8112 x 11 inches in size. �} N�� r, # f 017- <br /> • See reverse side for instructions for completing this application State Sanitary,Pe,mrt Number <br /> The information you provide may be used by other government agency programs .,A, ❑Cnoecck if revision to previous application <br /> (Privacy Law,z- 15.04(1)(m)I- la State Pla Oj umber ? <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF ORMMMM�ON ' /� ' �3 / -� <br /> PropertyOner Name Property Location S <br /> � re S k P 1/4 1/4,S a T 3 ,N, R /S E(ory:V <br /> Property Owner's Mailing Address Lot Number Block Number <br /> .2 y 7c C- Z 44'rA �� -5.4, A- J �City,State Zip Code Phone Number ubdivision Name or CSM Number <br /> )�(,5fer s 4�9 ( /S ) 349-s`1S vim /.•r e- stir . <br /> II. TYPE BUILDING: (check one) ❑ State Ownedity e 1s Nearest Road ff Q <br /> Public 1 or 2 FamilyDwelling- No. of bedrooms o rowan OF L-A'Pn/le / / ./-/114- <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) q <br /> 1 ❑ Apartment/Condo - �N / O 7-5-- o:2 <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 4_ ❑ 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 1AMound 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. Pert. Rate 6. System Elev. 7. Final Grade <br /> Required(sq. ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> 0 ,-, o Si:' .2507 9 9, 0 7 Feet / 6 /. Y Feet <br /> Capacity <br /> VII• INFORMATION in gallons Total #of Manufacturer's Name Prefab. Con- steel Site Fiber_ Past c Aper. <br /> New Existin Gallons Tanks concrete glass App. <br /> strutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank <br /> Lift Pump Tank/Siphon Chamber 5��'" ��� ®- <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:(N tamps) MP/MPRSW No.: Business Phone Number: <br /> Acle- RIly 14:71/ ,/,,,, t, J .-- tom- _-7Y9- 5.2s7 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 6o, < Sy y Sii— ,-_ ,i' c - 3 fr72 <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Perm Fee (includes Groundwater ate ssue Issuing Age Si natur Stamps) <br /> Approved ❑Owner Given Initial 7n11 Surcharge 7 Adverse Determination rpt c/ <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SOD 6398 Ul 05199) DISTRIBUTION: Original ro Ccnuo,O^e<.,,To: Saiery B Buildings Divnion,Owner,Plumber <br />