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fl SANITARY PERMIT APPLICATION C'gUw�J <br /> '`�n <br /> In accord with ILHR 83.05,Wis. Adm.Code `�" <br /> �ILH�t <br /> �.e. �....,�,�..e� STATE SANITARY PERM IT <br /> ;11 <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. PETITION <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES ❑ NO <br /> PROPERTY OWNEq , PROPERTY LOCATION <br /> R-Cn9rd hh -for- k—r- % )OW'/a, S TYO, N, R / B(0112— <br /> PROPERTY <br /> O WPROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCKNUMBER SUBDIVISIOr NAME <br /> W / 0-7 8 3 P � Al <br /> CITY,STATE ZIP CODE PHONE NUMBER CITY NEAREST ROAD,LAKE OR LANDM RK <br /> r -S, <br /> O VILLAGE: IC 4 <br /> II. 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. *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. XConventional 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. X Seepage Bed b. ❑Seepage Trench c. ❑ Seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 15.SYSTEM ELEVATION 6. WATER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): �p <br /> r (/0 'Y a / • Feet ®Private ❑Joint ❑ Public <br /> CAPACITY <br /> VI. TANK in allons Total #of Prefab. Site Fiber- Exper. <br /> INFORMATION Manufacturer's Name Con- Steel Plastic <br /> New xisting Gallons Tanks Concrete strutted glass App. <br /> Tanks Tanks O <br /> Septic Tank or Holding Tank C, Zt El <br /> Pum Tank/Siphon Chamber El ❑ 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): Plu er's Signature: No stamps) <br /> MP/MPRSW No.: Business Phone Number: <br /> o d er/c a 7{-rin r >/is- ) 6d 13 <br /> Number's Address(Street,City,State,Zip Code): Name of Designer: <br /> (v'eksT"r— W • r 3 <br /> VIII. SOIL TEST INFORMATION <br /> Certified S it Tester/LCST)Nam CST}/ <br /> I\ (C Q r d q7 � iY1..f � o 0 <br /> CST's ADDRESS(Street,City,State, ip Code) Phone Number: <br /> P66� <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee Groundwater Date Issuing Agent Signature(No Stamps) <br /> Approved ❑ Owner Given Initial GA S r harge Fee <br /> Adverse Determination OL)10 <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 />