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SANITARY PERMIT APPLICATION <br /> aILHR C LINTY <br /> _ In accord with ILHR 83.05,Wis. Adm. Code <br /> S AT/rE`S(AANIITARY ERM <br /> //I_T_# j� <br /> �CJ bCz I-6! q <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than SATE PLAN I.D.NUMBER <br /> 8'h x 11 inches in size. <br /> -See reverse side for instructions for completing this application. PE 71TION <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. F R VARIANCE ❑YES ® NO <br /> PROPERTYOWNER PROPERTY LOCATION <br /> u q n f.;c- (-L-11,5 %, S T yO N, R S 41 (or) W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISI N NAME <br /> 3 77�f}v. R1= a csn„ voC /o q D#.13 aP61 <br /> CITY,STATE ZIP CODE PHONE NUMBER 0 CITY NE TOAD,LAKE OR LAN M/ARK/-. <br /> S / OZz- 3-!1 $ 17 VILLAGE: G S Q n1 d r�j`"�. sff P <br /> If. 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. �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 Agreem nt to County Copy. <br /> IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2) <br /> 1. I b. ®Alternative c. ❑ Experimental <br /> 2. a. ❑System- b. tidT Holding c.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP <br /> In-Fill Tank <br /> V. ABSORPTION SYSTEM INFORMATION: (Check one) <br /> 1. ❑ See a e Bed b. rench c. ❑ Seepage Pit <br /> 2. PERC ABSORPTION AREA 14. ABSORPTION AREA 15.SYSTEM ELEVATION 6. W TER UPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): <br /> Feet ❑ rivals ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in allons Total #ofI Prefab. Fiber- Exper. <br /> INFORMATION New xistmg Gallons Tanks Manufacturer's Name Concrete Con- Ste glass Plastic App <br /> Tanks I Tanks structed <br /> Septic Tank or Holding Tank 004 It A4 C. ❑ <br /> 1:1 El <br /> Lift Pump 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:(No Stamps) MP/MPRSW No.: B siness Phone Number: <br /> o I I rh 6- Gd` <br /> Plumber's Address(Street,Citf,State,Zip Code): Name of Designer: <br /> r <br /> J <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name CST# <br /> n1tt3s` <br /> CST'sADDR S(Street,City,State,ate,Z' ode) Phone Num er16 q0 : <br /> 6 ar - sr <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved I Sanitary Permit Fee GroundwaterDate Issuin g ntS �Sps) <br /> Approved ❑ Owner Given Initial C>n. W Surchargee <br /> je) <br /> Adverse Determination bb 2 <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,Plumbs <br />