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• ••r•r> R Safety and Buildings Division <br /> a,ILSANITARY PERMIT APPLICATION Bureau of Building Water Systems <br /> In accord with ILHR 83 05,Wis.Adm.Code P O.Box 7969gton Ave. <br /> Madison,WI 53707-7969 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County 1 I <br /> than 8 112 x 11 inches in size. <br /> • See reverse side for instructions for completing this application State Sanitary RermltNumber�����er� <br /> The information you provide may be used by other government agency programs El Check it re isiun to previous application <br /> (Privacy Law,s. 15.04(1)(m)] State Plant .Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Name Property Location <br /> ADA U� f1V /a'( 1i _ 1/4,S /7 8 T AlD ,N, RI X(or)W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> o o nK / fio t/ AIA <br /> City,State ip Code Phone Number Subdivision Name or/ CSM umber Iy <br /> e 2/S 25V-7/26 <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ CitNea rest Road <br /> Public r 2 Famil Dwellin - No. of bedrooms —_ 1 vol age SCo� <br /> wn OF ALC A(y 7-/At&- <br /> III. BUILDING USE: (If building type is public,check alf that apply) Parcel vlTy <br /> T`axxN�(umber(s) <br /> 1 ❑ Apartment/Condo "�' -QM9!`('� 's-0 <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restau ant/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. U?Ww 2 ❑ Replacement 3_ ❑ Replacement of q ❑ Reconnectio of 5 ❑ Repair of an <br /> System System Tank Only Existing System ExistingSystem <br /> ----- -- 9 - - ------------------y---- <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 [gsterepage 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) Elevation <br /> �� .7 �� Feet v Feet <br /> Ca <br /> VII. ICapacity <br /> n gallons Total #of Manufacturer's Name Prefab Si Fiber- plastic Exper <br /> New Existing Gallons Tanks concrete steel glass App <br /> Tanks Tanks stru ted <br /> Septic Tank or Holding Tank apo 000 ( .$" /i'r:J 23— El ❑ ❑ ❑ <br /> L lft Pump Tank/Siphon Chamber ❑ El El ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown o the attached plans. <br /> Plumber's Name.(Print) Plumber's Signature pops) 1MPRSW No.: Business Phone Number. <br /> CiC SC i F <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 77/6 AoKrST/F.e A00 _7tYeL 4A:& Wj- <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> E]Disapproved Sanitary Pe mit Fee fm`maes,rourdwaier F-1 <br /> e Issue jIssum g nt sig ore( tamps) <br /> Approved ❑OwnerGivenlnitial —yj{�}L G `9eteP) C� I <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: <br /> SHO'4396 or 051l4) DISTRIBUTION: Original to Cnura y,one copy To: Sulety B Nui dhngf Diwvion,owner,Plu.b <br />