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ON COMPUTER/SCANNED7 �� <br /> Safety and Buildings ivision <br /> SANITARY PERMIT APPLICATION Bureau of Building Water 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(to the county copy only)for the system,on paper not less County <br /> than 8 1/2 x 11 inches in size. z5 /-"o *—> -t-f �/y� 33 <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> �v <br /> The information you provide may be used by other government agency programs 3w��" <br /> l Privacy Law,s. 1 5.04(1)(m)J. E]Check if revision to previous application <br /> 1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION State Plan I_D.Numbgrr��AA��//// <br /> Property Owner Name roperty Location 4. <br /> v- (/77A¢ZJ 11,3W114 A),01/4,S TZ,7_7N R f�E(or <br /> Pro ertyOwner's Mailing Addres Lot Numb <br /> a � teBlock Number <br /> (, r Number c _ <br /> City,State Zip Coe hone Number Subdivision Name or CSM Number <br /> _ e_r <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ Ci <br /> El Vitllay ge Nearest Road <br /> nn ` / <br /> Public 1 or 2 FamilyDwelling- No. of bedrooms �_ Town OF9//�N/ e-/ S i <br /> III. BUILDING USE: (If building type is public,checkallthatapply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo 00G— ,;2(//0 _0/ <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dinin <br /> 4 F1 Church/School 8 ❑ Mobile Home Park g <br /> 5 ❑ Hotel/Motel 12 ❑ Service Station/Car Wash <br /> 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. Replacementof <br /> ----"'System System ❑ 4. ❑ Reconnection of 5_ ❑ Repair of an <br /> Tank Only Existin S stem Existing System <br /> ------------------------------------------------- <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 KSeepage 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 /> Requl/7�d(sq. ft.) Pro .osed(sqft.) (Gals/day/sq. ft.) (Min./inch) Elevation <br /> �a � <br /> VII. TANK Capacity <br /> , <br /> Feet Feet <br /> INFORMATION in gallons Total #of Prefab Site Fiber- Exer. <br /> New Existin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App. <br /> Tanks Tanks strutted <br /> Septic TankorfT0tdmfj-Tank et P76 S ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> 1,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name:(PI t) Plumber's Signature.(No St mps) MP/MPRSW No.: Business Phone Number: <br /> L✓,�2� �c���vl� �G <br /> Plumber's Address(Street,City,State,Zip Code): <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee liorluaesGroundwater ate ssue Issuing A en ign ure( mps) <br /> proved ❑Owner Givenlnitial ] Surcharge Fee) <br /> V Adverse Determination / <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SRU 6398(R.05/34) DISTRIBUTION. Original to Cmu.iy.One ropy To: Safety 8 Ruildlogs Di .ion,Owner,Plumber <br />