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L)Yl C I <br /> Safety and Buildm s Division <br /> �ti�ai7n 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 1/2 x 11 inches in size. V <br /> • TID <br /> See reverse side for instructions for completing this application 5fate Sanitary PermitNNuumb�er <br /> The information you provide may be used by other government agency programs ❑Check it revis`ion to previous application <br /> [Privacy Law,s. 15.04(1)(m)]. <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Propert Owner Name Property Location <br /> E 1/4 1/4,S Zy T (� ,N, R E(or <br /> � <br /> Property Owner's Mailing Address Lot Number miner <br /> (652-a F_- Lk n. <br /> City,State Zip Code Phone Number Subdivis n Name r CSM Nusnbe(r �� <br /> AYtc leodE Mtf S5 41? )q2s-84g4 eCor /a Se <br /> If. TYPE OF BUILDING: (check one) ❑ State Owned ❑ rit� Nearest Road D <br /> E] Public 1 or 2 Famil Dwellin - No.of bedrooms ?' & Town OF 56017 <br /> :II. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) C� U p <br /> 1 ❑ Apartment/Condo 049 q1Z / 0 I Soo <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-'X' 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.Area3. Absorp.Area 4- Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade <br /> Req�[^red(sq- ft.) Proposed(sq. ft.) (Gals/day/sq. ft.) (Min-/inch) Elevation <br /> Elevation <br /> w <br /> 300 o &vo r S { Feet 9q.5 Feet <br /> VII. TANK Capacity <br /> INFORMATION in gallons Total #of Manufacturer's Name Prefab. Site Fiber- Exper <br /> New Existin Gallons Tanks Concrete Con steel glass Plastic App <br /> strutted <br /> Tanks �T7acnFks <br /> Septic Tank or Holding Tank 17 11q) -50/ W CP _P ❑ ❑ Q 'j ❑ <br /> Lift Pump Tank/Siphon Chamber �J (0 Oro I w ❑ � ❑ El El <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:(NoS mps) MP/MPRSW No.: Business Phone Number: <br /> Plumber's Address(Street,City,Stat ,Zip Code): <br /> W �e Wl• S 9 <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (Indudescroundwater ate Issue Issuing Age Signature(N S ps) <br /> pproved ❑Owner Giv / <br /> en Initial 5O p�Surchargefee) 7/ <br /> Adverse Determination / // Z <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.05/94) DISTRIBUTION: Original to(nunly,One copy To: Safety 8 Buildnigs Diveiun,Owner,PlumWr <br />