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c , <br /> SafetyandBuildings ivision <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 12 x 11 inches in size. <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> The information you provide may be used b other overnmenta enc programs Y P Y Y 9 agency P 9 ❑Check if revision to prevwus aUUlicafion <br /> (Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number nq n <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> PjqpertyOwnerName PropertyLccation j, <br /> r a!4 Iia,S t T 33 ,N, R ZS mor)W <br /> Property Owner's Mailin Address Lot Number Block Number <br /> Cit , tateZip Code Phone Number Subdivision Name or CSM Number <br /> l rt w Lv ( ) <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ City Nearest Road <br /> ❑ Village <br /> Public 1 or 2 Family Dwelling- No.of bedrooms Town OF lll�, B)eW 120 <br /> ill. BUILDIN USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> �� l — l <br /> 1 ❑ Apartment/Condo cl/V- o r goo <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- 4New 2- ❑ Replacement 3. E] Replacement of 4- ❑ Reconnection of 5. ❑ Repair of an <br /> 7- 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 /> 11V4,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.) Proposed(sq.ft.) (Gals/day/sq. ft.) (Min./inch) EI ttlion <br /> i 17 �� $ Feet % —Feet <br /> TANK Capacity <br /> VII. INFORMATION in gallons Total #of Manufacturer's Name Prefab. Con- steel Fiber- Exper. <br /> Gallons Tanks Concrete glass Plastic App <br /> New Existin strutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank 0e I &t_t ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ 1 ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> P mber's Name:(Print) Plumb ignature:(No Stamps) A4R/MPRSWNo-: Business Phone Number: <br /> s _ 3ase (63 - b'-;LSo <br /> Flties Ad res (Street,Cit ,State,Zip Code):Q — ✓�COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary P rmit Fee (includes Groundwater Date Issued Issuing Age t Sign ture( amps) <br /> Approved E]Owner Given Initial ��(� �w"na`9eFee) <br /> Adverse Determination ✓- cX1' `� 7� <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SHD-6398(B.05/94) DISTRIBUTION: Original to County,One copy To: Safety 6 Buildings Division,Owner,Plumber <br />