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..,,,...,:..4.._ ON r YI PUTE /SCANNED ( lj <br /> • <br /> RNt� . <br /> .,,i. SANITARY PERMIT APPLICATION Safety ofBBilidingWater's stem: <br /> �mix.nn <br /> In accord with ILHR 63.05,W .Adm.Code 201 E.Washington Ave. y <br /> P.O.Box 7969 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less coup Madison,WI 53707-7969 <br /> /6-65 4 <br /> than 8 1/2 x 11 inches in size. <br /> • See reverse side for instructions for completing this application State San ary P~r �/ \ . ) t <br /> Y e opreyott6er <br /> The information you provide may be used by other government agency programs lib `(T/ <br /> (Privacy Law,s. 15.04(1)(m)!- ❑C IFeck it revision to prey ous application , <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION State Plan I.D. ber ( <br /> Property Owner Name <br /> E.' i ) <br /> Property Location <br /> si~. /✓ f a c �/ 6 Property 1/4,5 3 5 " T._7f' ,N, R /,‘ E(o r)6 r <br /> Property Owner's Mailing Address <br /> LotNumfaer G JBlock Number ! <br /> city,State , Zip Code Phone Number r <br /> L:/'J (J4 /'e. G-' I-y 1.70 -1 I( ) Subdrviston_Nat I,or Number <br /> CTr- (17- Lt. <br /> II. TYPE OF BUILDING: (check one) 0 State Owned 0 city <br /> Public O Village <br /> Nearest Road <br /> 0 �1 or 2 Family Dwelling- No.of bedrooms 31 <br /> q Town OF/�'I€���1�i s"� /0049,-;516: �\ c <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 0 Apartment/Condo / e -3,3,35— t'7 7g0 --L <br /> 2 ❑ Assembly Hall 6 0 Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facilit <br /> 3 0 Campground 7 ❑ Merchandise:Sales/Repairs 11 & <br /> )12 <br /> 4 0 Church/School 8 0 Mobile Home Park ❑ Restaurant/Bar/Dining <br /> 5Hotel/Motel t 2 ❑ Service Station/Car Wash V41 <br /> 0 9 ❑ Office/Factory 13 0 Other: specify_ ,-,I <br /> IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B,if applicable) <br /> A) 1. y` `�System New 2. 0 Replacement 3• ElReplacement <br /> of 4. ❑ Reconnection of S. 0 Repair of an <br /> Only Existing System Existing System <br /> B) 0 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 BSeepage Bed 21 0 Mound 30❑Specify Type 41 0 Holding Tank <br /> 12 0 Seepage Trench 22❑In-Ground Pressure <br /> 13 0 Seepage Pit 42❑Pit Privy <br /> 14 0 SystemIn Fill 43❑Vault Privy <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) Elevation <br /> `-'ivL' X 0 0 , <br /> �%<'. r .-� . _�'- Feet 72 Feet <br /> III. TANK Capacity <br /> to gallons llons Tota! #of Prefab. Site <br /> . New Existing Gallons Tanks Manufacturer's Name Concrete Con- Fi <br /> Steel lasser- <br /> Plastic Aper <br /> Tanks Tanks strutted g bpp <br /> eptic Tank or Holding Tank o 7,`' ❑ ❑ El ❑ 0 <br /> 0 <br /> ift Pump Tank/Siphon Chamber ❑ 0 ❑ ❑ ❑ ❑ <br /> 1111. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> 'lumber's Name:(Print) Plumber's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> cd,4t/ ',,A—xo l 1 Z.,j t /'_ ,r y' S'Y <br /> lumber's Address(Street,City,State,Zip Code): <br /> K. COUNTY/DEPARTMENT USE ONLY <br /> 0 Disapproved SanitaryPermit Fee i'"�'°des Groundwater Date Issued <br /> Issuing Age Sig ture(Np •mos) <br /> ,pproved ❑Owner Given Initial �}r�5urcnarg¢r¢e) r P <br /> Adverse Determination / C` -� it 7(Y,E i�� •. <br /> CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br />