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Safety and Buildings Division <br /> �:�'iifr•' SANITARY PERMIT APPLICATION Bureau of Building Water System <br /> 201 E Washington Ave. <br /> In accord with ILHR 83 05,Wls.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 <br /> than 8 112 x 1 1 inches in size. tt <br /> • See reverse side for instructions for completing this application St/atpl Sanit r Permit Number <br /> The information you provide maybe used by other government agency programs ElC 0Ckvisiun to previous app C� <br /> (Privacy Law,s. 15.04(1)(m)I- State Plan I D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Propert Own ,Name Property Location / <br /> 'DAN 10 L 1/4 1/4,533 T Q ,N, R jb E(or W <br /> Property Owner's Mailing Addre s ��W -� Lot Number �I Block Number <br /> 2 D_ _ <br /> City,State ` ZI Code (h Ine Number -�''^ Subdivi i n Name or CSM NumberDANKI1, . <br /> II. TYPE F BUILDING: (check one) ❑ State Owned LU ❑ cit 7 S IANearest Road <br /> ❑ VII age �1 <br /> Public 1 or 2 Famil Dwellin - No. of bedrooms Town of o7l LiN (1 XP <br /> !11. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) My� <br /> 0 <br /> 1 F1 Apartment/Condo —CO"� — 10 <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 online B, if applicable) <br /> A) 1. ❑ New 2_`'Replacement 3. E] Replacement of 4_ E] Reconnection of S. ❑ Repair of an <br /> ------System System ------------- Tank Only Existing Sysi em 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 /> 1 1XSeepage Bed 21 ❑Mound 30❑Specify Type 41E] 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 E. System Elev. 7. Final Grade <br /> ((,n Re uireed (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Q p levation <br /> Poo O •7 10. 1 Feet Feet <br /> Capacit <br /> VII. INFORMATION n allons Total #of Manufacturer's Name Prefab o�_ fiber_ Plastic Exper <br /> New Existin Gallons Tanks Concrete Steel glass App. <br /> ed <br /> Ta�n�ksT Tankz <br /> Septic Tank or Holding Tank <br /> lift Pump Tank/Siphon Cham ber ❑ ❑ ❑ 0 <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned, assume responsibility for installation of the onsite sewage system shown n the attached plans. <br /> Plumber's Name:(Print) Plumb (s Ignature:(N Sta s) MP/MPRSW No.: Bu iness Phone Number: <br /> 1 G 0 ►f S UNC J`�� I�' <br /> PI mber's Address(Street,City,Stat ip Code): <br /> 2 w w� 51'5 W)- '57'1 <br /> IX. COUNTY/ DEPARTMENT SE ONLY <br /> ❑Disapproved Sanitary Per Fee pnd de,e,ound ale, 7,,ue,, Issui gAg n Signat re o amps) <br /> &Approved ❑Owner Given Inil I _ toAdverse Determination \-111-� <br /> X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: <br /> SUD-6398 UC 05/94) DMIRIRUTION. Original m Cnuray,Onempy To. Safer,&RuILIBny Dbcion.0--,,Plwn r <br />