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ON CO�,AP 1TER/SCANNED C& <br /> Safety and Buildings ivision <br /> ��■a�r>.r,t 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 Coun !� <br /> than 8 112 x 11 inches in size. 5� // \ ;? 0/ <br /> • See reverse side for instructions for completing this application State Sanitary Per rra tNu ber <br /> 7 n <br /> The information you provide may be used by other government agency programs ❑C 1l-eck it revision to prey ous application <br /> (Privacy Law,s. 15.04(1)(m)]. <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Name / Property Location <br /> A) c/-. 450145,E' 1/4,So 5— T,3q ,N, R /4�' E(or) <br /> Property Owner's Mailing Address Lot Num er Block Number I <br /> City,State Zip Code Phone Number Subdivision N omp or Number <br /> Lam _ <br /> 11. TYPE OF BUILDING: (check one) ❑ State Owned ❑ City lNearestRoad / <br /> 7��7n°S/ d <br /> ElPublic 1 or 2 Family DwellingE] Village <br /> - No. of bedrooms Town of e ��v <br /> III. BUILDING USE: (if building type is public,check all that apply) Parcel Tax Number(s) ��yL <br /> 1 ❑ Apartment/Condo J —333 'D - 6 7 7 <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facilit <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining S <br /> 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash U�W <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. p 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 NSeepage 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 /> f) %� t �-�� Feet 72-lSe Feet <br /> VII. TANK Capacity <br /> in gallons Total #of Prefab. Site Fiber- Ex per. <br /> INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel Plastic p <br /> New Existingstrutted glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank 7 E] ❑ El El El ❑ <br /> a�� <br /> Lift Pump Tank/Siphon Chamber ❑ 1 ❑ 1 ❑ ❑ ❑ ❑ <br /> VII(. 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:(No Stamps) MP/MPRSWNo.: Business Phone Number: <br /> Plumber's Address(Street,City,State,Zip Code): <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> (Includes Groundwater ate Issue Issuln A e Si t�(N <br /> Disapproved Sanitary Permit Fee g g g <br /> �� urchargefee) <br /> Approved ❑Owner Given Initial r!_ <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.05/94) DISTRIRUTIDN: nriainai to Cmmr.. non rnnv Tn• 4:;J r R R,.Il.;i nl.­.,,.. n.....e, m.....b, <br />