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Safety and Building Division <br /> Bureau of Building Water System! <br /> SANITARY PERMIT APPLICATION <br /> ■+9f� 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 <br /> than 8 1/2 x 11 inches in size. 7(0 <br /> • See reverse side for instructions for completing this application State SanitaryPeIIIrm/iittN9umber <br /> The information you provide may be used by other government agency programs ❑chec're�ion to pre i us 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 /> 114 1/4,5 T ( ,N, R b E(or)q) <br /> Property wner's ailing Address cc ``�'' Lot Number Block Number <br /> J.W- <br /> city,State Zip Code Phone Number Subdivision Name or CSM Number <br /> c ( 7 ) $o t-. Z S p. 3 <br /> II. TYPE OF ILDING: (check one) ❑ State Owned Cit Nearest Road <br /> Village <br /> Public 0 1 or 2 Fam ily DwelIin - No. of bedrooms Z' Town OF 5Vj L55 DU 29- <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo 032- 5333 -oZ - ZOO <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.-0 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 DCSSeepage Bed 21 El Mound 30[:]Specify Type 41 E] Holding Tank <br /> 1 Al 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.) Pro sed (sq. ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> 300 Z , 32 7. 8 Feet100.3 Feet <br /> TANK Capacit VII Site <br /> INFORMATION in all0 s Total #of Manufacturer's Name Prefab. Con- Steel Fiber- plastic Exper <br /> New Existin Gallons Tanks Concrete strutted glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding TankS tj ig El El 11 11ti ft Pump Tank/Siphon Chamber !g ❑ ❑ ❑ 1 ❑ ❑ <br /> Vill. 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 Signatur '(N tamps) MP/MPRSW No.. Business Phone Number: <br /> IC S <br /> Pumber's Ad E,(StreetCityState Zip Code): <br /> 2-11,60, 35 W) , 8 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> On <br /> Sanitary Permit Fee Ilndudes Gromdwater ate ssue Issuing Ag tSignature( Stamps) <br /> A roved barge tee) <br /> pp ❑Owner Given mi al <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SRD-6398(R.0SN4) DISTRIBUTION: Original to County,One cony To: Sulety BBuildings Divnion,Owner,Plumber <br />