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SANITARY PERMIT APPLICATION `ogVNTY <br /> C 51LHR ef'� <br /> In accord with ILHR 83.05,Wis. Adm. Code <br /> STATE SANITARY PERMIT# <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than STATk PLAN I.D.NUMBER <br /> 8'h x 11 inches in size. Sg�e�agy <br /> -See reverse side for instructions for completing this application. PETITION <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES ❑ NO <br /> P PERTY QpWNE36 PROPERTY LOCATION <br /> C s Loy S S 6%SE %, S T N,R `/ W <br /> PRO ERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME <br /> S�Qr {. I <br /> 13 ox 537 <br /> ITY,ST TE . ZIP CODE PHONE NUMBER CITY j NEAREST D AKE LANDMARK <br /> C( 6VYU. f 5�1� Q zs9 7 0 VILLAGE .12 TOWN Q / . <br /> II. TYPE OF BUILDING OR USE SERVED: v2 Cw F S <br /> Number of Bedrooms if 1 or 2 Family OR [/!i Public(Specify): o-�L a4Z <br /> Ill. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) <br /> 1. a. ❑ New b.Y 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. El 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. gConventional 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. N Seepage Bed b. ❑Seepage Trench C. ❑ Seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 14. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: <br /> (Minutes per inch): REQUII/RED(Square Feet): PROOP�OS (Square Feet): IST <br /> J T C ply( 9• �' Feet rp Private ❑Joint ❑ Public <br /> CAPACITY <br /> VI. TANK in allons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. <br /> INFORMATION New xisting Gallons Tanks Concrete glass App. <br /> Tanks Tanks strutted <br /> S Ta r Holdin Tank S S `-ei-er X I ❑ ❑ <br /> Lift Pum T nk/Si hon Chamber 000t�71 ❑ <br /> -RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for i stallation of the private sewage system shown on the attached plans. <br /> Plumber's arae(Pri t): Plum er's Si ature: No mpe) MP/MPRSW No.: Business Phone Number: <br /> �S � Luo s� �s s � <br /> Plu is ddress(Street,City, tate,Zip Code) Name o Desi ner: <br /> PSS <br /> VII . S91LTESTINFORMATION <br /> Cerfi -n Tester;e:&)lame p CST# 4 D, <br /> `C 1 Jv' I/ a <br /> CST' gDRESIre e[,City,State,Zi Cod � �L� � -el <br /> � Phone Number� — <br /> IX COl/TTUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sant ry Permit Fee Groundwater ate Issui gent Signatur (No Stamps) <br /> Approved ❑ Owner Given Initial SQQu..[[rcharge�reei,� <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 />