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O Safety and Buildings Division <br /> ,,���� SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> Nrisconsin P O Box 7302 <br /> In accord with ILHR 83.05,Wis.Adm.Code Madison,WI 53 07-7302 <br /> Department of Commerce <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. 3L <br /> • See reverse side for instructions for completing this applicati n State Sanitary Permit umber <br /> �a5�3 <br /> Personal informatiorf you provide may be used for secondary purposes E]Check i1 revision to previous application <br /> [Privacy Law,s. 15.04(1)(m)). State Plan I.D.Number <br /> I. APPLICATION INFORMATION- PLEASE PRINT ALL 1 dATI 13 r <br /> Property.Owner Name Property Location <br /> �JZICKSOIJ NI/J 1/4 va,Sag T,39 N, R) E(or <br /> 999V <br /> Property Owner's ailing Address Lot Number Block Number <br /> s OLD 357 <br /> City,Sate 2i ode Phone��II ber SubdivisionNameor MNumber 2-Z <br /> �,Sf1W LJ 1 3 ( l3) -YAD L 13 YN4 <br /> - <br /> II. T BUILDING: (check one) ❑ State Owned 0 LIXY Nearest Road <br /> Village � � <br /> � <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms Town of 1'tw" � <br /> Ill, BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 E] Apartment/Condo 6J8- �33a8- <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 El Mobile Home Park 12 ❑ Service Station/Car Wash <br /> 5 ❑ Hotel/Motel 9 ppffice/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. ❑ Replacement 3. ❑ Replacement of 4.AReconnection of 5, [:] Repair of an <br /> _System ____ __System ____ Tank Only_ ______ _��_EExistingSystem _ Existing System <br /> B) Sanitary Permit was previously issued. Permit Number 5 Date Issued <br /> V. TYPE OF SYSTEM: (Check only one) <br /> Non-Pressurized Distribution Pressurized Distribution Experimental Other <br /> 11 ❑Seepage Bed 21 ❑Mound 30❑Specify Type 41 [:]Holding Tank <br /> 12❑Seepage Trench 22,gbIn-Ground Pressure 42❑Pit Privy <br /> 13❑Seepage Pit 43❑Vault Privy <br /> 14❑System-In-Fill <br /> VI. ABSORPTION SYSTEM INFORMATI <br /> 1. Gallons Per Day 2. Absorp.Area 3. sor p.A ea 4. Loading Rate S. Perc. Rate 6. System Elev. 7. Final Grade <br /> Req i eddd�sq.ft.) ) (Gals/�yy�q.ft.) (Min./inch) �j Elevation <br /> S `—� �JS• Feet . Z-Feet <br /> VII. TANK `ItSite <br /> in gallons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- plastic Aper. <br /> INFORMATION New Existin Gallons Tanks concrete strutted glass App <br /> T nks Tan <br /> Septic Tank or Holding Tank <br /> Lift Pump Tank/Siphon Chamber El El I KI ❑ E <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:(Print) I Plumber's Signature:( o S ^ps) MP/MPRSW No.: Business Phone Number: <br /> 1 (,1/1/A��/�ljl <br /> Plu tier's Address(Stree ,city,State,Zip Code : Gni W1. SASLIS <br /> OC <br /> IX. COUNTY/DEPARTMENT USE OJQLY <br /> ❑Disapproved Sanitary Permit Fee (lndude"'ounee)dwater ate ssue Issuing Age Signature(No Stamps) <br /> Surcharge /�G� <br /> F <br /> pproved ❑Owner Given Initial /� <br /> Adverse Determination <br /> 7K.7—CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(RA 1/97) DISTRIBUTION: Original to County.One copy To: Safety 8 Buildings Division,owner,plumber <br />