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Safety and Buildings Division <br /> 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 t �� <br /> than 8 112 x 11 inches in size. StAilz/V -Iq6 <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 itrevisiont6 re�8s application <br /> (Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Numbe�A /,y f�. <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION �(� <br /> Property Owner Name Property Location <br /> rrwon4v 14EZIL161/4 1/4,S ?;(,,, T q-I N, R lb E(or)(@ <br /> Property Owner's dlaili66 Address Lot Number Block Number <br /> 3 DAIRVIA14V <br /> City,State Zi Code Ph vie Number Subdivision Name or SM Number <br /> t \41. 40015 (7/5 )825-3-254 51JISS I ESTATES <br /> II. TYPE OF BUILDING: (check one) p State Owned El City Nearest Road <br /> Public 1 or 2 FamilyDwelling � V <br /> -No.of bedrooms owan OF SW 15S r 6Q Q- <br /> III. BUILDINGUSE: (If building type is public,check all that apply) Parcel TaxNumber(s)q <br /> 1 ❑ Apartment/Condo 03z_ <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.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 /> 30 0 2 ,'7 4.0 Feet s Feet <br /> VII. TANK Capacit In gallons Total #Of Prefab. Site Fiber- plastic Exper. <br /> INFORMATION New Existin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass App <br /> Tanksl Tanks strutted <br /> Septic Tank or Holding Tank !1D 0 O ,eS ❑ ❑ ❑ El El <br /> L.Ift Pump Tank/Siphon Chamber I 1 ❑ El I o o T ❑ ❑ <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 <br /> Signature:(N Sps) MP/MPRSW No.: <br /> 3c rS <br /> P mber'sAddress(Street,City;Stat Zip Code): Business-Ph$on6e 6Number:Q <br /> S7 <br /> ES til r . 59$ 3 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (Indude5Groundwater Date Issued / Ilssuing A t natur (N t s) <br /> ❑Owner Given Initial <br /> )PAWoved Surcharge Fee) �!/J// <br /> �✓� <br /> Adverse Determination �JU <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.05/94) DISTRIBUTION: Original to County.One copy To: Safety 8 Buildings Division,Owner,plumber <br />