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r <br /> Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION Bureau of Building Water Systems <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 my <br /> than 8112 x 11 inches in size. Co9UrP-e74V Q <br /> • See reverse side for instructions for completing this application State Sanitary Per�i�ur ber <br /> ly <br /> The information you provide may be used by other government agency programs ❑Che�,kf revision to previous application <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION �1 Gt IS ,jJ <br /> ProQperty Owner Name Property Location <br /> JO�h �{ C L(Ah (OT'Y`� I ( '� K C1/4SE 1/4,S3 q T L/0 ,N, R I�,&4or) <br /> Property Owne.C4 Mailing Address Lot Number Block Number <br /> :, D, 5 O `(r 10 <br /> Civ,State Zip Code Phone Number Subdivision Name or CSM Nu^lher <br /> J]i-� 1] S�Fr�7 Z (7/5-)3`14-523y Gv 1 fees S b o 2- <br /> 11. <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ ity Nearest Road <br /> ❑ Village <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms 3 Town OF 04 Klancl 61>A (S Ltk�!_ <br /> III. BUILDING USE: (If building type is public,checkallthatapply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo 0,r�o M 0/ CPLOO <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, N 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 PSMound 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 /> 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 /> y 37.� 3-1 � t , Z 97• �3, Feet r,?3 Feet <br /> 1- Gallons Per 37 <br /> � -] <br /> Ca acit <br /> VII. INFORMATION in gallons Total a of Manufacturer's Name Prefab- Con- Steel Site Fiber- plastic Aper. <br /> New Existin Gallons Tanks Concrete structed glass App. <br /> Tanks Tanks <br /> Septic T k or Holding Tank /0_( I-e tAC r_1El❑ ❑ ❑ <br /> l t Pum T� k/Siphon Chamber X oo I ❑ ❑ ❑ ❑ ❑ <br /> RESPONSIBILITY STATEMENT <br /> [,the undersigned,assume responsi ility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name:(P - t) IP tuber's Sign to :(No Stamps) MP/MPRSW No.: Business Phone Num er: <br /> Pumber's.Address(Street,tity,State,Zip Code) <br /> : <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved San,.i ry Perm ncludesGroundwater ate ue Issuing Agent ign amps) <br /> pproved ❑ / 5°riargeFee) <br /> Owner Given Initial <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SND-6398(B.05194) DISTR18UTION: Original to County.One copy To: Safety 8 Buildings Division,Owner,Plumber <br />