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C� �IL.HR SANITARY PERMIT APPLICATION C04UTY (l <br /> In accord with ILHR 83.05,Wis. Adm. Code <br /> s STATE SA'NIIITARY PERMIT# <br /> T ' IITI <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 ❑YES ❑ NO <br /> PROPERTY OWNER PROPERTY LOCATION <br /> Facer scaso.,s /Ica/ �'/a �W/a, S Irl T N, R E (or <br /> PROPE TY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUB VISION NA E <br /> Q' e <br /> CITY,STAT�j , ZIP CODE PHONE NUMBE CITY NEAREST ROAD,LAKE OR LANDMARK <br /> /rIC lU rry� SSQ37 �� -7 VTOWN OR <br /> ILLAGE : <br /> 11. TYPE OF BUILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family, rOnOz5 OR ❑ Public (Specify): <br /> III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) <br /> 1. a. X 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. 11 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. gConventional b. ❑Alternative C. ❑ Experimental <br /> 2. a. ❑System- b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound I. ❑ IGP <br /> In-Fill Tank <br /> V. ABSORPTION SYSTEM INFORMATION: (Check one) <br /> 1. a. See a e 13 ed 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): PROPOS/ED( quare Feet): (// Fes' <br /> /0 �/ 97 (` Feet J�UPrivate ❑Joint 11 Public <br /> VI. TANK CAPACITY Site <br /> in cellons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> T�n1annk�ks Tanks strutted <br /> Septic Tank or Holdin Tank Nv 7M ❑ ❑ ❑ <br /> Lift Pum 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): Plumber's Signatur No Stamps) MP/MPRSW No.: Business Phone Number: <br /> lAladf AF�sfio/m GrJ� 1_�36/ �/S 81a�-7a�Ci <br /> Plumber's Address(Street,City,Slate,Zip Code): I Name of Designer: <br /> r e. 5 5 cr/e63fer k/l9>l /& /70/.,-� <br /> VIII. SOIL TEST INFORMATION <br /> Certified SoiIT est r(CST)Name CST# <br /> e ,L�tr� 91575 <br /> CST's ADDRESS(Street,City,State,Zip Code) Phone Number: <br /> R2me /S �P <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee Groundwater <br /> � <br /> QcaTte,I C, <br /> Iss �gent Signature(,W Stamps) <br /> Approved E] Owner Given Initial Surcharge Fee <br /> Adverse Determination Ja5.cv <br /> X. COMMENTS/REASONS FOR DISAPPROVAL: i <br /> v' <br /> SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber <br />