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SANITARY PERMIT APPLICATION <br /> 4� DiLHR In accord with ILHR 83.05,Wis. Adm. Code <br /> � �•---,�-o. ST TESANITARY ERMIT# <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D. UMBER <br /> 8'h x 11 inches in size. <br /> —See reverse side for instructions for completing this application. PE ITION <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOI I VARIANCE ❑VES ❑ NO <br /> PROPERTY OWNER PROPERTY LOCATION <br /> -7HCM &,vCQS jR Al '/4 OIJ Ck)'/4, S T , N, R E (o W <br /> PROPERTY OWNER'S MAILING ADDRESS' LOT NUMBER BLOCK NUMBER SUBDIVISI N NAME <br /> ,.nm2C �• 3S ! Z9 A,'4- D�--�z 9oD.7", ✓ I/, <br /> CITY,STATE ZIP CODE PHONE NUMBER CITY NEAREST AD,LAKE OR LANDMARK <br /> .I 3 VILLAGE:Jj_TOWN Jam/«� 7P9/� tAc <br /> OF <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. 1KNew 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. Aconventional 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. See a e Bed b. ❑ Seepage Trench c. ❑ Seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.S M ELEVATION 6. WATER SUPPLY: <br /> (Minutes p r inch): REQUIRED(Square Feet): PROPOSED(Square Feet): <br /> 6�� 277 'D Feet P ivate ❑Joint ❑ Public <br /> CAPACITY VI. TANK #of Prefab. Site Fiber- <br /> in allons Total Manufacturer's Name Con- Stee Plastic Exper. <br /> INFORMATION New xisting Gallons Tanks Concrete glass App. <br /> Tanks Tanks structed <br /> Septic Tank or HoldingTank ��� In. (f El <br /> Lift Pump Tank/Siphon Chamber ❑ I ❑ ❑ ❑ ❑ <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): Plumyer`s-Spnature: o Stamp MP/MPRSW No.: Bu iness Phone Number: <br /> heaJA/-/) E. r �I t / Ev/ - Cc_ I o7a- <br /> Plumber's Address(Street,City,State,Zip Code): Name of Designer: <br /> VIII. SOIL TEST INFORMATION <br /> CertifiedSoil Tester(CST)Name CST# <br /> CST's ADDRESS(Street,City,State,Zip Code) Phone Number <br /> Kt 3 19,5e, Y, -1-2C <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee Groundwater ate Ise g gent Si atur o Stamps) <br /> Approved ❑ Owner Given Initial per,/y�., S" hha5e Fee �� s <br /> Adverse Determination <br /> C:U LJI J s <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 />