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SANITARY PERMIT APPLICATION Safety of BDdd�Sy <br /> Bureau a hingtn Waters stem' <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 L <br /> than 8 112 x 11 inches in size. (,tingtl 1?5_7-7 <br /> • See reverse side for instructions for completing this application State Sanitar 9N�bvr// <br /> The information you provide maybe used by other government agency programs []Check it revision to previous as ocation <br /> [Privacy Law,s. 15.04(1)(m)L <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INE ORMATI N 1 <br /> IProperty wner Name 1Properky LocaUOn7 ,�} <br /> i' T�- S ,14S Watt, 3 T a g ,N, R /G-k4o� <br /> Pjgperty Owner's Mailing Address Lot Number Block Number <br /> V30 tlee "a-63 <br /> Cit ,`tate ZSCodeO Z Pone Number Subdi isiod Name or CSM Num erA <br /> Zone <br /> 12-)22 dd R 6U xL e4 <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ Cit I Nearest koad <br /> ❑ Village LN kS ff <br /> Public 1 or 2 Famil D ellin - No. of bedrooms Town OF bbleellox S d. <br /> III. BUILDI NG USE: (If buildi ng type is public,check al l that apply) Parcel Taxx Number(s) <br /> 1 ❑ Apartment/Condo 10 lT _! 17`S — 30d <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. ® 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;KHo[dingTank <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 It IFORMATION: <br /> 1.Gallons Per Day 2. Absor .Area 3. Absorp.Area 4. Loading Rate, 15. Perc. Rate 1 6. System Elev. 17. Final Grade <br /> /S� Require (sq.ft.) Proposed(sq.ft.) (Gals/day/sq. ft{) (Min./inch) Elevation <br /> y Feet <br /> TANK Capacity <br /> VII. INFORMATION in a[lons Total #of Manufacturer's Name Prefab Site Con- Steel Fiber- Exper <br /> Gallons Tanks concrete glass Plastic App <br /> New Existin strutted <br /> Tanks Tanks <br /> Septic Tank in I( O ❑ I ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ I ❑ l ❑ ❑ I ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume re ponsibil' y for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name: Pri t) Plu ber's S- nature: No amps) MP/ PRSW No.: Business Phone Number: <br /> e(S C-Pr r Irl �57?(� —10 <br /> Plumber's Address(St t,City, tate,Zi C e):� <br /> 700'rf W U XdY/. <br /> itt), <br /> IX. COUNTY/ DEPARTMEN USE ONLY <br /> ❑Disapproved Sanitap Permit I, W nodes Groundwater Date Is e IssuingAgent igna ur ( ps) <br /> roved na`ge`eet <br /> (1J�pp ❑Owner Given Initial <br /> � <br /> // Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD 6398(R.05N4) DISTRIBUTION: Original to County.One copy To: Safety 8 Bwildings Division,Owner,PlumEer <br />