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Safety and Buildings Division <br /> is i i 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 County-r-:, <br /> than 8 112 x 11 inches in size. /- _P)` <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> The information you provide may be used by other government agency programs Check B revision to previous application <br /> (Privacy Law,s. 15.04(1)(m)]. State Plan I.D.DNumber <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Pr p y net Narn,e. I Property Location ,�;� <br /> kA_,o 1/�i,<,/ 1/4,S310 T ,/TO •N• R l0 <br /> Property Ow r'S M I inp Addr 55 Lot Number Block Number <br /> .� `I I, n <br /> City,St Zip Code Phone Number Subdivision Name or CSM Number <br /> (VLN 770 <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned oty Nearest Road <br /> ❑ Village //// <br /> Public 1 or 2 FamilyDwelling- No. of bedrooms Town of $ M46414 4k via <br /> III. BUILDING USE: (If buildingtype is public,check allthatapply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo U L Z- _ 4 L 3<o , Oro-1 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] Replacementof 4. E:] Reconnectionof 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 /> I 1A 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.) Pr osed sq. ft.) (Gals/da sq. ft.) (Min./inch (� r— EI vation <br /> W !3 J Feet 7 Feet <br /> Ca act <br /> VII. INFORMATION in gallons Total #of Manufacturer's Name Prefab SiteCon- steel Fiber- Plastic Exper <br /> New Existin Gallons Tanks concrete sv OD glass App <br /> Tank Tanks <br /> Septic T r Holding Tank ® ❑ ❑ ❑ ❑ ❑ <br /> rft Pu ank/Siphon Chamber ® ❑ ❑ ❑ ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT 6&V11 0 — <br /> I,the undersigned,assume responsibil y for insta 0atiop of the onsite sewage system shown on the attached plans. <br /> Plum er' Na e:(Pri t) bar's Sig <br /> Plu nat S' oStamps) MP/MPRSW No.: Business Phone Numb r: <br /> PI er's Add reess(St ree it ,Stat Zip Cod <br /> CL , (r <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (includes Groundwdter ate sue IssuingAge tsig tur ( tamps) <br /> roved �6 Sur harge fee) <br /> p ❑Owner Given Initial <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FO APPROVAL: <br /> SBD-6398(R.05/94) DISTRIBUTION: Original to County,One copy To: s.ou,&Ruimm,rimnion,Owner,Plumber <br />