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SANITARY PERMIT APPLICATION C UNTY <br /> �3 DILHR In accord with ILHR 83.05,Wis.Adm. Code u <br /> S TE SANITARYP MIT# <br /> -Attach complete plans(to the county copy only)for the system, on paper not less than S1 ATE PLAN I.D.NUMBER <br /> 8%x 11 inches in size. <br /> -See reverse side for instructions for completing this application. <br /> PE TITION <br /> 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FC R VARIANCE OYES ❑ NO <br /> PROPERTY OWN `� PROPERTY LOCATION <br /> /-/t/ �/ yt d/Z 6L. '/a 17 '/a, S /3 T Q, N, R E (0 <br /> PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME <br /> krl <br /> CI Y, ATE ZIP ODE PHONE NUMBER CITY NEAREST OAD,LAKE OR LANDMARK <br /> C -� 715 Q�+-y��� r VILLAGE: vN104) <br /> /-/y/ un clr;L C ic'p tl <br /> 11. TYPE OF BUILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family c1 OR ❑ Public(Specify): <br /> III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4, if applicable) <br /> 1. a. QNew b.❑ Replacement c. ❑ Replacement of d.❑ Reconnection of e.❑ Repair of an <br /> System System Septic Tank Only an Existing System Existing System <br /> 2. ❑ A Sanitary Permit was previously issued. Permit# Date Issued <br /> 3. ❑ An Existing System has been inspected and soil conditions meet minimum requirements. <br /> 4. ❑ The System is shared by more than one owner/building. Attach Common Ownership Agreeri nt to County Copy. <br /> IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2) <br /> 1. a.19conventional b. ❑Alternative C. ❑ Experimental <br /> 2. a. ❑System- b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. IGP <br /> In-Fill Tank <br /> V. ABSORPTION SYSTEM INFORMATION: (Check one) <br /> 1. a. XSeepage Bed b. ❑SeeDacie Trench C. ❑ See a e Pit <br /> 2. PERCOLATION RATE 13. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. W TER SUPPLY: <br /> (Minutes per inch): REQUIRED Square Feet): PROPOSED(Square Feet): / r <br /> lO 9i y -6 Feet ®P ivate El joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in allons Total of Prefab. Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Stee glass Plastic App <br /> Tanks Tanks structed <br /> Septic Tank or HoldinTank S 5� <br /> Lift Pum Tank/Sipon Chamber ❑ El I D 1 ❑ <br /> VII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Plumber's Name(Print): Plumgnature:( Stamp _ MP/MPRSW No.: T <br /> Business Phone Number: <br /> 4• ne T ,O c 3o'�a- .s- a>.�i� 3soy <br /> Plumber's Address(street,City,State,Zip Code): Name of Designer: <br /> 4170 Code). // <br /> 0, S YB30 <br /> VIII. SOIL TEST INFORMATION <br /> Certified ' Tester(CST)Name CST# <br /> ell <br /> CST's ADDRESS(Street,City,State,Zip Code) Phone Numb <br /> 5,W) 71i :2 %3S o <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved San�ita^ry Permit Fee Groundwater ate Issuing Agent Signature(No Stamps) <br /> Approved ❑ Owner Given Initial W S rcchharge Fee <br /> / \ Adverse Determination - `o `'iso <br /> X. COMMENTS/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION. Orin i..at to County,One Copy To:Bureau of Plumbing,Owner,Plumber <br />