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I <br /> Safety and Buildings Divl Ion <br /> Viwonsin SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> P O Box 7302 <br /> Department of Commerce <br /> In accord with Comm 83.05,Wis.Adm.Code Madison,WI 53707-7302 <br /> • Attach complete plans(.o the county copy only)for the system,on paper not less County <br /> than 8 12 x 11 inches in size. State SS�anitary Permit Numb r 93 <br /> • See reverse side for instructions for completing this application <br /> Personal information you provide may be used for secondary purposes ❑Check it revlslon to previous application <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> 1. APPLICATION INFORMATION - PLEASE PRINT ALL INF ORMATProperty ocation IION <br /> Property Owner Name 1�4 1/4,5 T_T ,N, R 1% E(or]@ <br /> O 5 IIA-c- Lot Number Block Number <br /> Property Owner's Mailing Ad{(res;� �r <br /> N e w, -3 ._..+ <br /> S3 ��.r-Fre <br /> City,State Zip Code Phone Number S on Name o�SM Nurpb�rO <br /> ,tJe_� dr,t h� a ( ) V <br /> y Nearest Road <br /> TUTYPE E B ILDI G: (check one) E] State Owned _ �❑ Village �I j eche nJ � ?Q <br /> 71 Public 1 or 2 FamilyDwelling-No.of bedrooms Town OF <br /> III. BUILDING USE: (If building type is public,check all that apply) <br /> Parcel Tax Number(s) <br /> 0/8 <br /> 1 ❑ Apartment/Condo Outdoor Recreational Facility <br /> 2 El Assembly Assembly Hall 6 ❑ Medical Facility/Nursing Home ❑ <br /> 3 ❑ Campground11 Restaurant/Bar/Dining <br /> 7 ❑ Merchandise:Sales/Repairs ❑ <br /> ❑ <br /> 4 ❑ Church/School 8 ❑ 12 Service Station/Car Wash <br /> Mobile Home Park 13 C] Other: specify <br /> 5 ❑ Hotel/Motel 9 ❑ office/Factory <br /> IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B,if applicable) Re air of an <br /> New 2. Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair <br /> ng A) 1. ❑ Dg_Replacement <br /> Exist- System -__------E-----System <br /> ___ 5 stem System --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 E]Seepage Bed 21 ❑Mound 30[3 Specify Type 41 jg FHolding Tank <br /> 22❑In-Ground Pressure 42 E]Pit Privy <br /> 12[3 Seepage Trench 43❑Vault Privy <br /> 13[]Seepage Pit <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.Pert. Rate 6. System Elev. Elev7. lationnal Grade <br /> Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min_/inch) Fee � Feet <br /> t <br /> VII. TANK Capauty Total #of Prefab. site Fiber- plastic Exper. <br /> INFORMATION in gallons Gallons Tanks Manufacturer s Name Concrete con- steel glass /+PP <br /> New Existin strutted <br /> Tanks Tank <br /> Septic Tank or Holding Tank b El ElLift Pump Tank/Siphon Chamber ❑ ❑ El <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:(N to PS) MPlMPRSW No.: TB5usiFesSPhFone Number: <br /> `/ 7�pt! <br /> Plumber's Address(Street,City,State,Zip Code): <br /> o S'�5� fir- G•./ W 19' 7 2 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee <br /> (includes ate ssue IssuingAp7JQntSignature(Nostamps) <br /> ❑ pp Surcharge tee) ���� <br /> Approved E]Owner Given Initial q� I-�sr <br /> Adverse Determination —ar <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> DISTRIBUTION: original to County.One copy To: Safety&Buildings Division,Owner,Plumber <br /> SBD-6398(R.W99) --- — _-- <br />