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_ DIr'\ C '` <br /> Safety and Buildings Division <br /> � V�ln SANITARY PERMIT APPLICATION Bureau of Building Water System <br /> 201 E.Washington Ave. <br /> In accord with[LHR 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 /� 76-1than 8112 x 11 inches in size. G a/'/✓r <br /> • See reverse side for instructions forcompleting thisapplication state Sanitary Permit Number <br /> The information you provide may be used b other overnmenta enc programs / ��� <br /> Y P Y Y 9 agency P 9 ❑Check it revision m Ureviuus aUUBcalion <br /> [Privacy Law,s. 15.04(1)(m)I. <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION 2� <br /> Prope yOwner Name `Property Location ``,,��1, <br /> Z11-1 S-3C 1116114 .5 1/4,S /� Tay N• R/6 E(orXF) <br /> Property Owner's Mallin Address Lot Number Block Number <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> w4vlvy4h�er (,JTS.;s9 '7 <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned E] itr Nearest Road / <br /> E] Public 1 or 2 FamilyDwelling- No.of bedrooms 0 Townn of /27 /A �d <br /> :11. BUILDING USE: (if building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo 96 o <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 E] Reconnection of 5. E] 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 /> NonPressurizedDistribution 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 5. Perc. Rate 6. System Elev. 7. Final Grade <br /> Required(sq. ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> vU -3 7-5— 37S ss /O O Feet /0�2,XFeet <br /> Capaclt <br /> VII. INFORMATION in allons Total #of Manufacturer's Name Prefab Site Con- Steel Fiber- plastic Exper <br /> New Existin Gallons Tanks Concrete glass App <br /> strutted <br /> Tanksl Tanks <br /> Septic Tank or Holding Tank Poe C) ®- ❑ ❑ ❑ ❑ ❑ <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) Plumber's Signature:(5gstamps) MP/MPRSW No.: Business Phone Number: <br /> Plumber's Address(Street,City,Sate,Zip Code): <br /> Z?&)-r- S/' _5//`e/'J 2--1 <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> E]Disapproved Sanitary Permit Fee,(IW.de,eroundwater ate Issue Issuing A a Sign re( m s) <br /> pproved ❑Owner Given Initial exs�r<nargefeel <br /> Adverse Determination �C <br /> X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: <br /> $PD b39P(P-0594) DISTRIBUTION Original1n Cnuniy.One ropy io: 5efeiy&PuiLlin9s Dlm:.ion,owner,PlumGer <br />