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Safety and Buildings Division <br /> (Ei <br /> SANITARY PERMIT APPLICATION Bureau 201 E.WaaBuildingWaterSystems <br /> shington 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 W <br /> ��than 8 112 x 11 inches in size. er it Nu ber• See reverse side for instructions for completing this application /°'�/ `'The information you provide may be used by other government agency programs on to previous application(Privacy Law,s. 15.04(1)(m)]. Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Prope Owner Name /� gropertl�Location <br /> IPA J y�4iA : G- 1/4,S T Ye ,N, R/,SE(or)W <br /> Property Owner's MaiingAdd r ss Lot Number Block Number <br /> 16 <br /> Cit State Zip Code Phone Number Subdivision Name or CSM Number <br /> City, <br /> taw s rii.0 rfo 33 ( >Y3 C6 S o l`�cd/ Firs t/ <br /> ;r✓ <br /> I1. TYPE F BUILDING: (check one) ❑ State Owned ❑ city L Nearest Road <br /> Public 1 or 2 FamilyDwelling- No.of bedrooms a Town OF AC/ � S S ea/ Fir t✓p'� <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) Z <br /> 01.2 - 96 so - o� �� C <br /> -50- ov L / <br /> 1 ❑ Apartment/Condo <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Fcfcility <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 5New 2- ❑ Replacement 3, ❑ Replacement of 4- ❑ Reconnection of 5. OR <br /> epair of an <br /> S stem System - __ Tank Only _____________ Existing System_ _ Existing System <br /> Y ------ <br /> B) p 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 /> 11eepage Bed 21 ❑Mound 30[:1 Specify Type 41 ❑Holding Tank <br /> 12 ]MSeepage 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 Al- Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade <br /> Re( red(sq. ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> '30 C �4 a4-00 • S — 570/, 2 Feet Fal• 6 Feet <br /> Ca acit <br /> VII. TANK in allons Total #of Prefab. Site Fiber- plastic Exper- <br /> INFORMATION g Gallons Tanks Manufacturer's Name Concrete Con- Steel glass APP <br /> New Existin strutted <br /> Tanks Tanks / ❑ ElSeptic Tank or Holding Tank i�6lJ �D a L s Li ❑ ❑ ❑ <br /> I ift Pump Tank/Siphon Chamber <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:(Pr nt) y- Plumber's Signature:(No Stamps) MP/MPRSW No.. Y��7 <br /> s Phone Numb: <br /> GJ Ade- �4IL`S�i o � - G �� 6 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 13 0 —°' .Si!' , W Y <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ('"`Odeseroundwater Date Issue ssuingAge ntS N <br /> nature o St <br /> ❑Disapproved Sanitary Permit Fee <br /> /66—) �.dLr(hargefee) <br /> ❑Approved ❑Owner Given Initial / <br /> [ V / �p <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SHD-6398(B-05/94) <br /> DISIRIBUTION: OriginalmCourd y.One a+Py Ta: Safety&Buildings Divrion,owner,Plumber <br />