Laserfiche WebLink
SANITARY PERMIT APPLICATION COUNTY -- 1 <br /> � DILHR In accord with ILHR 83.05,Wis.Adm. Code r <br /> STATE SANITARY PERMIT# <br /> Q C)(C 030� <br /> —Attach complete plans (to the county copy only)for the system, on paper not less than STATE PLAN I.D. UMBER <br /> 81/2 x 11 inches in size. <br /> —See reverse side for instructions for completing this application. PETITION <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES ❑ NO <br /> PROPERTY OWNER PROPERTY LOCATION <br /> sl l kv, Gr` 46r r '/o SA'% S ;L S- T QrO, N, R /�' (or) W <br /> PRgPERTY OWNS'S MAILINGOADDRESS LOT NUMBER BLOCK N�IMBER SUBDIVISION NAME <br /> I Al <br /> CITY, TATE 8 ZIP CC/ODDE PHONE NUMBER /CIIIT`Y/tTJ �{— NEARESTNAR'OA LAKE OR LAN M/ARK/- <br /> WC�rTrr `'lJl. S rfp DO TnWNQF <br /> O VILLAGE : JQ �SOA1 ' LaEA •C <br /> It. 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 /> p <br /> 1. a. Ld 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. 117r <br /> Lp.j 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. ® Seepage 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): i PROPOSED(Square Feet): <br /> d"7 IJ ! Feet Private ❑Joint ❑ Public <br /> V1. TANK CAPACITY Site <br /> in allons L #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. <br /> INFORMATION New xistings Tanks Concrete glass App. <br /> Tanks Tanksstrutted <br /> Se tic Tank or Holdin Tank 0 to C. ❑ <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): Plumb-isDSi_gnature:( o Stamps) MP/MPRSW No.: Business Phone Number: <br /> pD 4',wl C i n r C 0� 0- ?/S ( ls-7 <br /> Plumber's umber's A dress(Street,City, tate,Zip Code Name of Designer: <br /> �l cl <br /> Vlll. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name CST# <br /> O e t�lc a c <br /> CST's ADDRS(Sire 1,City,State,Zip Cod ) Phone Number <br /> E : <br /> lu-e <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee Grondwater ate Issui gent Signat r (No Stamps) <br /> Approved ElOwner Given Initial �/^t^) �q(,-,� Surcuharge Fee <br /> Adverse Determination ""'• �� <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 />