Laserfiche WebLink
SANITARY PERMIT APPLICATION COUNTY <br /> 7DILHR In accord with ILHR 83.05,Wis.Adm.Code U <br /> mum S1 ATE SANITARY PERMIT# <br /> a i33aq <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than S ATE PLAN I.D.NUMBER <br /> 8'h x 11 inches in size. <br /> —See reverse side for instructions for completing this application. <br /> PE TITION <br /> 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES ❑ NO <br /> PROPERTY OWNER EaV <br /> ERTY LOCATION <br /> /Q3 5- �/ '/a Sit/Y4, S /7 T V1, N, R J E (or <br /> PROPERTY OWNER'S MAILING ADD UMBER BLOCK NUMBER SUBDIVISI N NAME <br /> CITU,STATE ZIP CODE PHONE NUMBER ITY NEAREST CAD,LAKE OR LANDMARK <br /> Y S �../ �'^a �, — ., ILLAGE: 5w1� <br /> II. TYPE OF BUILDING OR USE SE•R`+VED: / <br /> Number of Bedrooms if 1 or 2 Family clf 64r4OC176 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 Agreem nt to County Copy. <br /> IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2) <br /> 1. a. 9 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. X Seepage Bed b. ❑ Seepage Trench c. ❑ Seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. W TER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): i PROPOSED(Square Feet): n /% <br /> /Q 7`� 'Y1'7 Feet F rivate ❑Joint ❑ Public <br /> CAPACITY <br /> VI. TANK Site in allons Total <br /> INFORMATION #of Manufacturer's Name Prefab. Con- Steel Fiber- plastic Exper. <br /> New xisting Gallons Tanks Concrete strutted glass App. <br /> Tanks Tanks <br /> Septic Tank or Hot Tank /.� s� ElEl <br /> Pum Tank/Si hon 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 S ps) MP/MPRSW No.: B siness Phone Number <br /> Lt/ �3hr>/m 3347 7/5 o(o-7�7R'v <br /> Plumber's Address(Street,City,State,Zip Code): Name of Designer: <br /> �X�?S yt/e6.s��r k/I 61 Woo'e. Za by <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name CST# <br /> jAlade- 15 fF-3 <br /> CST's ADDRESS(Street,City,State,Zip Code) Phone Numt er: <br /> ,Bo s c.GwIi-I•; u/r s/Fp,3 7/s 9lolP 7a�a <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved I Sanitary Permit Fee Groundwater Date Iss Ing ent Si nat oStamps) <br /> Approved ❑ Owner Given Initial C-nS rchage Fee <br /> Adverse Determination 1-4(NU.cc ry/ —q g <br /> X. COMMENTS/REASONS FOR DISAPPROVAL: <br /> L <br /> SBD-6398(formerly Plb-67)R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumbe <br />