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.quo WI Fa/t)-D -7 e'r '1AsP&A`J <br /> Safetyand Buildings Division <br /> SANITARY PERMIT APPLICATION Bureaof Building Water Systems <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 <br /> than 8 1/2 x 11 inches in size. S&/-A)e <br /> • See reverse side for instructions for completing this application State Sanitary Perm Number <br /> The information you provide may be used by other government agency programs / �� <br /> (Privacy Law,5. 15.04(1)(m)I. <br /> 9 Y P 9 ❑Ch" a revision to previ s application <br /> State Plan I .Number/ <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Name _tProperty Location c- <br /> r@ u r / A�LI r.1 v4 E v4,S T �� N, R ( V E(or)© <br /> Property O ner's Mailing Address Lot Number Block Number <br /> O IPJ, <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> G er /�� _qk/ ( >G7s-79.1 <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned Li Clt Nearest Road <br /> ❑ Public ❑ 1 or 2 Famil Dwellin - No. of bedrooms li vi t(age n 11 / <br /> lirTown OF SG O <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 I] Apartment/Condo 0o2 8 4//33 O �� D <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. XReplacement 3. ❑ Replacement of q ❑ 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 ;4 Seepage Bed 21 ❑Mound 30❑Specify Type 41 ❑HoldingTank <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 /> z© Requi0 sq. ft.) Proposed(sq.ft.) (Gals/da /sq.ft.) (Min./inch) Elevation <br /> 6 3- Feet Feet <br /> VII. TANK Capacity <br /> INFORMATION in gallons Total a k Manufacturer's Name Prefab. Site Fiber- Plastic Exper <br /> New Existin Gallons Tanks Concrete Con- Steel glass App <br /> Tanksl Tanks I <br /> strutted <br /> Septic Tank or Holding Tank Dq ❑ ❑ El <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:(Pri t) Plumber's Signature:(No5 amps) MP/MPRSW No.: Business Phone Number: <br /> Fs/ol'o, I Z_ Jac-c� avq- 7��� <br /> Plumber's Address(Street,City,State,Zip Code): <br /> O --c— .S// Ir t,✓� �—f�8 02 <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (includes Groundwater rate Issue issuing Agent nat re amps) <br /> A roved l surcharge Fee) /PP ❑Owner Given Initial <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS F R ISAPPROVAL: <br /> SRD-6398(R.05/94) DISTRIBUTION: Original to(nur,ly,one copy To: Safely 8 Puilt Ings Division,Owner,Plumber <br />