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SANITARY PERMIT APPLICATION COUNTY <br /> fl DILHR In accord with ILHR 83.05,Wis.Adm. CodeU <br /> STATES AN ITARYP RMIT# <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.ftMBER <br /> 8'h 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 LINO <br /> PRp,OfERTYOWN''ER// PROPERTY LOCATION <br /> &UMC �,v/�6Q 7 TVO, N, R/S E (o <br /> PROPERTY OWyER'SILIc ADD SS LOT NUMBER �VtOC U SUBS�ME <br /> v 7M <br /> %�y7/1�,1TEN i3,m`.J� ZI�`SPSCOC•Dj=� NUMBER � CITY : TNEA�S ROAD,LA EOR LANDMARK <br /> /77/� CO_I�J <br /> /W_ <br /> BE VILLAGE : C/ <br /> TOWN OF <br /> 11. TYPE OF BUILDING OR USE SERVED: / <br /> Number of Bedrooms if 1 or 2 Famil)e� be' li51ai 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.gReplacement c. ❑ Replacement of d. ❑ Reconnection of BE 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. OConventional 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. Seepage Bed b. ❑ Seepage Trench c. ❑ Seepage Pit <br /> 2. PER OLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: <br /> (Minutes er inch): REQUIRED/(Square Feet): PROPOSED(Square Feet): nom/ <br /> Cf/� 7�� `� /• Feet Private ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank = ❑ —1EJ <br /> 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 Signature:(N tam s) MP/MPRSW No.: Business Phone Number: <br /> UIOLL_ �u /ao/m Q� X310/ 7/S Gia 7��1v <br /> Plumber's Address(Street,City,State,Zip Codej: Name of Designer: <br /> 4&VIV TIMI X&.S. 1040. ,&X446 kkby/ti,bell 15�ubtar &161))a/m <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil TesterST)Name CST# <br /> kloa(e &//m0//" 315-1?3 <br /> CST's ADDRESS(Street,City,State,Zip Code) Phone Number: <br /> carne 7/s 860!0- <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee Groundwater gte Issui gent Signat (No Stamps) <br /> Approved ❑ Owner Given Initial YI. 4l� M e charge Fee [} n <br /> Adverse Determination _L'\U OBJ �,plJ� XU Y �� <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 />