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SANITARY PERMIT APPLICATION cTY 0e*(:___ <br /> � - <br /> � DILHR In accord with ILHR 83.05,Wis. Adm. Code <br /> STATE SANITARY ERMIT# <br /> � g 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'h x 11 inches in size. <br /> -See reverse side for instructions for completing this application. PE TITION <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. F R VARIANCE ❑YES ❑ NO <br /> PROPERTY OWNER PROPERTY LOCATION <br /> T " o rY r- E %SE %, S -3/ T 5/D,4d, FI r 1�(or)W <br /> PROPERtY <br /> OWNER'S MAILING ADDRESS LOTNUMBER BLOCK <br /> /NUMBER SUBDIVISION NAME <br /> 4 R h IQ I A, /" A <br /> CITY,$TAT \ ZIP CODE PHONE NUMBER 8S3 Li CITY0 VILLAGE : NEAREST OAD,LAKE OR LAfJDMARK <br /> webxJ�f w - SK �f� �C, 10 AJ <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. M Replacement c. ❑ Replacement of d.❑ Reconnection of e ❑ Repair of an <br /> System System Septic Tank I an Existing System `I 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 Agreemc nt to County Copy. <br /> IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2) <br /> 1. a. 0 Conventional 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. Rseepage Bed b. ❑Seepage Trench c. ❑ Seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 15.SYSTEM ELEVATION 6. W TER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): <br /> �1 �p/,5 6 V 9�'� peel [2F,ivate ❑Joint ❑ Public <br /> CAPACITY <br /> VI. TANK in allons Total #of Prefab. Site Fiber- Exper. <br /> INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Ste I glass Plastic App <br /> Tanks Tanks structed <br /> Septic Tank or Holdino Tank 7 ( UPC_ ❑ <br /> Lift Pum Tank/Siphon Chamber ❑ ❑ ❑ El ❑ ❑ <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): Plu is Signature:(N Stamps) MP/MPRSW No.: Business Phone Number: <br /> o (I le r-I C Ff ri o kl`iv_ � �3 os iT �C i '-VIT 77 <br /> Plumber's Address(Street,City,State,Zip Code): Name of Designer <br /> VIII. SOIL TEST INFORMATION <br /> Ce ed 71,Tester(CST)Name CST# <br /> o .0r`Ic / o !T ( tis �3 7 <br /> CST's ADDRE S(Street,City,State,Zip Code) Phone Numb r: <br /> w S �� 7111- 926 6 W7 <br /> W. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved I Sanitary Permit Fee Groundwater ate Iss gent Si re(No Stamps) <br /> X.Approved ❑ Owner Given Initial 15 V. S c�h7arge Fee �j� <br /> Adverse Determination V '✓�-S• ® <br /> X. COMMENTS/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber <br />