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Buildings Division <br /> r�•■�n■■ 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 /0� <br /> than 8 12 x 11 inches in size. r <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> The information you provide may be used b other government agency programs 1 "5�3 <br /> Y P Y Y 9 9 Y P 9 ❑Chec rewsion to previous application <br /> [Privacy Law,s. 15.04(1)(m)). State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property O"w�nerme Property Location v <br /> w E =Jil 1/4 1/4,S I S T N, 114 &il w <br /> Property Owner's ilirQlAddress Lot Number Block Number <br /> L5 Lof 2— <br /> City, <br /> City,Stat Zip Code Phone Number Subdivision Name or CSM Nu ber <br /> Heir W 1 I( I V3 VI-73 <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ City ae Nearest Road <br /> Public 1 or 2 FamilyDwelling- No. of bedrooms 2— volwn OF QAII_ <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo oN- 311$-OZ- a4co <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. 2rNew 2- ❑ Replacement 3- ❑ Replacement of q ❑ 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 ErSeepage 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 S. Perc. Rate 6. System Elev. 7. Final Grade <br /> Required (sq. ft.) Proposed(sq.ft.) (Gals/day/sq-ft.) (Min./inch) Elevation <br /> 300 413Z. • 7 *Joe- h 9 / Feet .3 Feet <br /> TANK Capac <br /> VII INFORMATION in allons Total #of Manufacturer's Name Prefab Site Con- Steel Fiber- Exper. <br /> Gallons Tanks Concrete glass Plastic App <br /> New Exist ng strutted <br /> Tanks Tanks <br /> Septic Tank o H I� � k ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the unclersignef&&Kne responsi itity for instal tion of the onsite sewage system shown on the attached plans_ <br /> Plumber's "s Si gnat :(NoStam s) fIrMMPRSWNo.: Bus+ eNumber, <br /> 11E & EXCAVATI g p r.7M0 <br /> Ill CouM Cone Rd. X 5/875 <br /> Plumber's Address h Code): <br /> (715)635.7482 <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Issuin Signa' ( s) <br /> c(�proved ❑Owner Given Initial L—,� C-0 surcnargelee) <br /> Adverse Determination ✓a 7� <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> 500-6398(1.05l94) OKTMILITION Original to Courtly,One Copy To: Safety&Nuildings Dimt,on,Owner,Plumber <br />