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wlSeonsin Fund..- at L, r <br /> _ Safety and Building[Division <br /> "" •.�+ SANITARY PERMIT APPLICATION Bureau of Building Water Systems <br /> f�y�Lt1f7 201 E.Washington Ave. <br /> In accord with ILHR 83 05,Wis.Adm.Code P.O.Box 7969 <br /> Madison,Wt 53707-7969 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County p <br /> than 8 112 x 11 inches in size. I G '/i-.0 <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> a 5c <br /> The information you provide may be used by other government agency programs ❑check it revision to previous application ^ <br /> [Privacy Law,s. 15.04(1)(m)). State Plan LD.Ny mber V� <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION 5t77-— �O(/ 9 0 9 <br /> Pro ertX Own r Name Prop rty Location <br /> SG 6r u Z 5Lc�111415 JI/4,S S T I IN, R E (or)tIVV7 <br /> Prop/eerty Own s Mailing Address Lot Num er Block Number <br /> ,� ? <br /> V V 7, — Z-k- V <br /> City,State L Zip Code Phone Number Subdivisi n Name or CSM Number <br /> [I. TYPE F BUILDING: (check one) E] State Owned 111t Nearest Road <br /> -91 <br /> Public or 2 FamilyDwelling- No. of bedrooms 3 a Toown F h1�t u' c� dmf z k K-1 <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Ta. Number(s) <br /> 1 ❑ Apartment/Condo C - <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home i 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 , if applicable) <br /> A) 1. ❑ New 2_ M Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5. ❑ Repair of an <br /> System ' ystem _ ______ 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 /> Nom Pressurized Distribution Pressurized Distribution (Experimental Other <br /> 11 ❑Seepage Bed 21 ❑Mound 130❑Specify Type 41 ❑ Holding Tank <br /> 12❑Seepage Trench 22XIn-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 Ra:e 5. Perc. Rate 6. System Elev. 7. Final Grade <br /> Required (sq. ft.) Pr q.ft.) (Gals/day/sq. t.) (Min./inch) c� Elevation <br /> L/SC) Feet Feet <br /> Ca aut <br /> VII. INFORMATION n g Ilons Total #Of prefab Site Steel Fiber- plastic Exper <br /> Gallons Tanks Manufacture "s Name Concrete Con- glass App. <br /> New Existin strutted <br /> Tanks Tanks 11 <br /> Septic Tank or Holding Tank 1&,r,J a0 C / �y. ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber E D�' Zn c? 'LJ ❑ ❑ -1El ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite se age system shown on the attached plans. <br /> Plumber's Name: (Print) Plumber's Signature:(No Stam s) M /MPRSWNo : Business Phone Number: <br /> ar�sLc�w G✓-m��� Z <br /> Plumber's Address(Street,City,State,Ztp Code): <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (Includes GroundwaterT7,75-IT <br /> ng Agen ignature o amps) <br /> charye lee) <br /> Approved ❑Adver, Given Initial /�6 U Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL <br /> SND-6398(8.W94) DISIBIBUTION- Originaltn Counly.Onempy Tu: S�lety BuilJinge Dim,mn,Owner,Plumber <br />