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( LLLILHR SANITARY PERMIT APPLICATION COUNTY <br /> In accord with ILHR 83.05,Wis. Adm. Code <br /> STE SANIT ERMIT# <br /> S �K3 <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than S1 ATE PLAN I.D.NUMBER <br /> 8Yz x 11 inches in size. <br /> —See reverse side for instructions for completing this application. PETITION <br /> 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FC R VARIANCE ❑YES ❑ NO <br /> PROPERTY OWNEKMA�ILING� <br /> ,,//,, PROPERTY LOCATION <br /> W//L L /AA�OD 5/D '% 'Al/l' S T , N, R ) w <br /> PROPERTY OWNEAD RESS LOTNUMBER BLOCK NUMBER SUBDIVISI N NAME <br /> 'k 5 /CITY,STATE ZIP CODE PHONE NUMBER CITY NEAREST OAD,LAKE OR LANDMARK <br /> C / (7/5 .VILLAGE : <br /> 11. TYPE OF BUILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family 3 '40"Ill OR ❑ Public (Specify): <br /> Ill. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) <br /> 1. a. ❑ New b.AReplacement 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 <br /> ei�inn,r#1 and only one in#2) <br /> 1. a. ❑Conventional b. L-A`Alternative C. ❑ Experimental <br /> 2. a. [-]System- b.X 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. ❑ Seepage Bed b. ❑Seepage Trench c. ❑ Seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 15.SYSTEM ELEVATION 6. W AJER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): <br /> Feet [IFIrivate ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Ste glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdino Tank 1fiDG� OZ r �t� <br /> Lift Pump Tank/Siphon Chamberl ❑ TFT ❑ <br /> VII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plan . <br /> Plumber's Name(Print): Plumber' Signalu e�(No Stamps) MP/MPRSW No.: B siness Phone Number: <br /> �ENNF C fz- /�sf ?077 7i5 4/69 3� / <br /> PI tier's Address treet,City,State,Zip Code): Name of Designer: <br /> S4t 1 ;70 <br /> Vlll. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name \ CST# <br /> CS 's ADDRESS(S reel,City,State,Zip Code) Phone Number: <br /> Xt— .c _,e c -0 70 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee Groundwater ate Issuing Agent S gnature(No Stamps) <br /> S rcharge Fee /� <br /> pproved ❑ <br /> OwnerGivenL.fl 19°l\ I' ,fes /7���. �f <br /> Adverse Determination C,WV V`/ Q(� / �Q Y �C <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,Plumbe <br />