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.i 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 County ?6 <br /> than 81/2 x 11 inches in size. 4 s^ � 7 <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> -0 77 <br /> The information you provide may be used by other government agency programs C]Check if revisi�o previous application <br /> ]Privacy Law,s. 15.04(1)(m)]- State Plan I.D.Num e <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION � � ! go to y7 <br /> Property Owner Name Property Location <br /> ,- -;r 1/4 1/4,S a T,3Y ,N, R / E(or) Ali <br /> P7rfy Owner's Mailing.Address Lot Number Block Number <br /> G A!3 0 02 <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number // 47 <br /> t � Lg�� G✓ � YL (8Od )3fcX—/u7`� f.i ^ z P_-fs C N <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ City Nearest Road <br /> ❑ Village <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms Town of .D Q _' <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 0- glad - ©a <br /> 1 ❑ Apartment/Condo <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. 5 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 ❑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 /> , 0 J — — — FeetI Feet <br /> TANK Ca aat <br /> VII INFORMATION in allons Gaollons Tanks CPrefab <br /> cebe site glass App- <br /> g Manufacturer's Name coD- steel Plastic <br /> New Existin strutted <br /> Tanks Tanks <br /> Septir�or Holding TankOr�O �',>a00 S �— ® ❑ ❑ ❑ ❑ ❑ <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:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> / <br /> Plumber's Address(Street,City,State,Zip Code): <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fed (In`�udes crounawater ate sue Issuing Agent ignat re S ps) <br /> loved � surcharge Fee) <br /> pp ❑Owner Given Initial / �.� � 29 <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.05/94) DISTRIBUTION: Original to County,One ropy To: safety&Ruildings Divi ion,Owner,Plumber <br />