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1..." \ C J <br /> W"p Safety and Buildings Division <br /> 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 <br /> than 8 112 x 11 inches in size. qgNeTr <br /> • See reverse side for instructions for completing this applicationState SanitaryPerrmiit Number <br /> The information you provide may be used by other government agency programs ❑Checaev8n to p f�s application <br /> [Privacy Law,s. 15.04(1)(m)I. <br /> State Plan I.D. um e <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Name Property Location <br /> SR E h'1/4 1/4,S 7 LO T N, R 16 E(or& <br /> Property Owner's ai ing Address Lot NumbeC Block Number <br /> (0613 LDLJ n. <br /> 5 1 <br /> City,State Zip Code Phone Number Subdivision Name or 44SM Number <br /> Th <br /> RN wl . ( 5> - o33 S EN lV JI �✓ RKK <br /> II. TYPE F UILDING: (check one) ❑ State Owned L] Cit <br /> Nearest Road oU(A4 p2 <br /> Public 1 or 2 FamilyDwellingE] Vill-No.of bedrooms �� Town OF <br /> III. BUILDING USE: (If buildingtype is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo 03Z 91Z5 07- 30o <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. Ig Replacement 3- ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> System System Tank Only Existing System Existing System <br /> ----------------------------------------------------------------------------------------------- <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 96 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 /> Sob Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Mine) 8-O Elevation <br /> 32 ,7 Feet �D, Feet <br /> Capacity VII. FORMATION in gallons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. <br /> New ExistingGallons Tanks Concrete structed glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank _0 5� / ❑ El El El <br /> Lift Pump Tank/Siphon Chamber Gp ❑ ❑ ❑ ❑ ❑ <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 Signatur :( Stamps) MP/MPRSW No.: Business Phone Number: <br /> IcN8Qp Kix ,d ] 16- 66- 15 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> WEWS <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (includes Groundwater ate Issye Issuing Agen ign or =S) <br /> 1/�y ✓ Surcharge <br /> `j�,4pproved [:]OwnerGive Initial �� /D <br /> Adverse Determination I <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.05/94) DISTRIBUTION: Original to County,One copy To: Safety&Buildings Division,Owner,Plumber <br />