Laserfiche WebLink
SANITARY PERMIT APPLICATION °°�NTY <br /> O DILHR In accord with ILHR 83.05,Wis.Adm.Code �v rn -e <br /> pSTATE SANITARY PERMIT <br /> q 3o3a <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 /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. I FOR VARIANCE ❑YES ❑ No <br /> PROPERTY OWN PROPERTY PROPERTY LOCATION p <br /> Q r t�oi-p"& YX >W % 6'�<, s ( r�fo , N, R ! -&*OD <br /> PROPER OWNER'S MAILINGADDRESSLOT NUMBER BLOCK NUMBER SUBDIVISION NAME <br /> c .Z L -70 Q <br /> CITY,PTATEZIP CODE? PHONE NUMBER CITY : NEAREST ROA OR LANgMQK <br /> J (K J VILLAGE : <br /> II. TYPE OF BUILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family 3 OR ❑ Public(Specify): <br /> III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) <br /> 1. a. ❑ 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. ,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. Elseepage Trench c. ❑ Seepage Pit <br /> 2. PER OLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: <br /> (Minutes per inch): REOUI ED(Square Feet): PROPOSED(Square Feet): G� c <br /> �5 j(j�CJ / 7�. {."t Private ❑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- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Se tic Tank or Holding Tank boo I III) t-s1 na ❑ 11 ❑ <br /> Lift Pump Tank/Siphon Chamber 1 ❑ ❑ ❑ <br /> VII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility f I <br /> installation of the private sewage system shown on the attached plans. <br /> Plumber's Name(Print): I PI mbar' ignat re: o Stamps) MP/MPRSW No.: Business Phone Number: <br /> .P(S k�-,Pv ter INP 778't/ 71 S-) eF66--Xa8 <br /> Plumber's �S <br /> Address(Stre t,City,State,Zip Code): Name of Designer: <br /> 'Z �oS <br /> ¢ �Pr C ,yet P &Oe!40t <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name CST# <br /> (,c , h,p /f/r 11' 055- 7 <br /> CST's AD RESS(Street,City,State,Zip ode) Phone Number: <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved I Sanitary Permit Fee Groundwater ate Issuing ant Signature(No Stamps) <br /> pproved ❑ Owner Given initial 60 S rcharge Fee _ �� S <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 />