Laserfiche WebLink
(ZITMitH I SANITARY PERMIT APPLICATION COUNTY <br /> In accord with ILHR 83.05,Wis.Adm. Code <br /> STATESANITARYPRMIT# <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. PETITION <br /> 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑VES ❑ NO <br /> PR PERTYOWNER —` PROPERTY LOCATION <br /> Fr / M�zr PLJ%3 E %, S 3s 1V , N, R @(or W <br /> PROPERTY OWNER'S MAILING ADDR SS LOT NUMBER BLOCKNUMBER SUBDIVISION NAME <br /> CITY,S TE , ZIP CODE PHONE NUMBER CITY NEAREST ROAD,LAKE OR L NO RK <br /> El VILLAGE <br /> II. TYPE 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. P@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. rAseepaae Bed b. ❑Seepage Trench c. ❑ See a e Pit <br /> 2, PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): <br /> S_ `9.?-� Feet Private El Joint ❑ Public <br /> CAPACITY VI. TANK CASite <br /> in gallons Total #oiPrefab. Fiber- Exper. <br /> INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks I Tanks structed <br /> Se tic Tank or Holding Tank 0\1 l.J'tL-062 11 <br /> Lift Pump Tank/Siphon Chamber ❑ <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): Plum Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> a a3 �� f- <br /> Plumber's Address(Street,Citq,Slate,Zip Code): S Name of Designer: <br /> t_,� " �� S <br /> VIII. SOIL TEST INFORMATION <br /> Certified So Tester Name CST <br /> cR <br /> '/1 Q/ J <br /> CST's ADDRESS(Street,City,State,Zip C de) Phone Number: <br /> !L T It, r / <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sa nary Permit Fee Groundwater ate Is ung ent Signature tamps) <br /> Approved ❑ Owner Given Initial 1('� i I,4-lr'/� QS4lrchaLrge(F�eee <br /> Adverse Determination "" -r+a`�'c7t) <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 />