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SANITARY PERMIT APPLICATION ITTE <br /> NTY <br /> � DILHR In accord with ILHR 83.05,Wis. Adm.Code r <br /> SANITARY PERMIT# <br /> X13 C ht <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than ST TE PLAN I.D. JMBER <br /> 8%x 11 inches in size. <br /> -See reverse side for instructions for completing this application. PE ITION <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. Fo VARIANCE ❑YES ❑ NO <br /> PROPERTY OWNER PROPERTY LOCATION <br /> yCL �.l t/a S� a, S 36 T ild, N, R i V E (oryo <br /> PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISI N NAME <br /> /FO ,r ee led, 60V <br /> CITY,STATE ZIP CODE PHONE NUMBER CITY NEAREST AD,LAKE OR LANDMARK <br /> ..r�dOS` F VILLAGE : ! h/. <br /> TOWNJ / J L C/ C <br /> 11. 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. �0 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 Agreeme it to County Copy. <br /> IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2) <br /> 1. a. 2 Conventional b. ❑Alternative c. ❑ Experimental <br /> 2. a. ❑System- b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. 11 IGP <br /> In-Fill Tank <br /> V. ABSORPTION SYSTEM INFORMATION: (Check one) <br /> 1. a.I Seepage Bed b. ❑seepage Trench c. ❑ Seepage 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): G <br /> 5// ill 0 7`r 7 Feet JX P ivate ❑Joint ❑ Public <br /> VI. TANK CAPACITY <br /> n allons Total #of Prefab. Site Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Stee glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank ✓ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber I Lj I ❑ El Ej ❑ ❑ <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 er's Signature:(No Stamps MP/MPRSW No.: Business Phone Number: <br /> cT 1 /Pl lrc kj o 6 O ..2 u 3 <br /> Plumber's Ad ess(Street,City,State,Zip Code Name of Designer: <br /> r O'n't <br /> Vlll. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name CST# <br /> v/ '? 3 � <br /> CT's ADDR S(Street,City,State,Zip Code) Phone Number: <br /> v / �d <br /> IX COUNTY/DEPARTME T USE ONLY <br /> ❑ <br /> Disapproved S nitary Permit Fee Groundwater at Iss g A ent Si n re(No Stamps) <br /> pproved ❑ Owner Given Initial rI S charge Fee <br /> Adverse Determination ° ` •/n / v" <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 1 <br />