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SANITARY PERMIT APPLICATION COUNT <br /> 1 31LHR In accord with ILHR 83.05,Wis.Adm.Code r <br /> s STA SANITARY PERMIT# <br /> a <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBER <br /> 8'%x 11 inches in size. <br /> —See reverse side for instructions for completing this application. PL <br /> 1:1I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. F R VARIANCE YES ❑ NO <br /> PRypER YOWNER E�PROPERTYLO�CATION <br /> 9t / S e�(� TyDN, R V JF(or)W <br /> PROPERTY OWNER'S MAILING ADDRESS BLOCK NUMBER SUBDIVI I N NAME <br /> " ?0 `f l J /4 v S )v far ACITY,STATE ZIPCODE PHONENUMBER NEAREST OAD, AKE OR LANDMARK <br /> � B h'Y1 - sy/ &C*6 /ra-r- hi's /J <br /> II. TYPE OF BUILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family OR ❑ Public(Specify): <br /> III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) <br /> 1. a. ® New 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 Agreement to County Copy. <br /> IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2) <br /> 1. a. Conventional b. ❑Alternative C. ❑ Experimental <br /> 2. a. ❑System- b. ❑ Holding C.11 Pit Privy d. ❑ Vault Privy e. ❑ Mound f. I❑ IGP <br /> In-Fill Tank <br /> V. ABSORPTION SYSTEM INFORMATION: (Check one) <br /> 1. a. ®seepage Bed b. ❑seepage Trench c. ❑ seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. W. TER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): <br /> L/ �j e! p <br /> / 3 f 07. 0 Feet Irivate []Joint ❑ Public <br /> CAPACITY <br /> VI. TANK Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks structed <br /> Septic Tank or Holding Tank �sd T 1-1 ❑ ❑ L-1Lift Pump Tank/Si hon Chamber Flc� ❑ I ❑ I I ❑ ❑ <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): Plumber'se:(No Stamps) MP/MPRSW No.: B siness Phone Number: <br /> o t o i n r � U 3 e S1_ /� Q� - /.- <br /> Plumber's Addreps(Street,City,State,Zip Code):S F? Namg,o(Designer: <br /> VIII. —OIL TEST INFORMATION (j CJ <br /> Certified Soil Tester(CST)N e CST# `�,7 <br /> 6 n/ G �J! �," / <br /> CST's <br /> AODDRESSUNTY/DSEtreet`City,State,Zip Code) Phone m e <br /> Wit , NfV'y<S <br /> PARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee I Groundwater ate Issu Agent Si nau (No Stamps) <br /> jApproved S rchargeFee❑ Owner Given Initial 1_/1•� -Q_4 <br /> Adverse Determination 11(��JJ V <br /> X. COMMENTS/REASONS FOR DISAPPROVAL: <br /> r <br /> SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County.One Copy To:Bureau of Plumbing,Owner,Plumbe <br /> 7 <br />