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SANITARY PERMIT APPLICATION COUNTY <br /> �:Y U71LHR In accord with ILHR 83.05,Wis. Adm. Code jrnefk <br /> STATESANITARY ERMIT# <br /> 114 ( <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBER <br /> 8%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 ❑ves ❑ No <br /> PROPERTY OWNERPROPERTY LOCATION <br /> Rea I /4u ''a, S Tf�t) , N, R � �' a (0 W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME <br /> h <br /> T•O• 0 -if /UA /: rC/4"r 10Plc1er P1&I <br /> ff <br /> CITY,STA ZIP CODE PHONE NUMBER LJ CITY NEAREST RO ,LAKE OR LANDMARK <br /> ❑ VILLAGE : " 0 d w <br /> It. TYPE OF UII DING 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. N 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. Si 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. XSeepage Bed b. ❑Seepage Trench c. ❑ See a e Pit <br /> 2. PERCO05,71ON RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): <br /> Vzo 3 / ry ./ Feet Private El joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in gallons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- plastic Exper. <br /> INFORMATION New xistin Gallons Tanks Concrete glass App. <br /> Tanks Tanks t� strutted <br /> Septic Tank or HoldingTank V kI C ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ I ❑ <br /> VII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plans. <br /> PI Tiber's Name(Print): Plu Sig ature:(No Stamps MP/MPRSW No.: Business Phone Number: <br /> Plumber' Address(Street,City, tate,Zip Co a Name of Designer: <br /> VIII. SOIL TEST INFORMATION <br /> Cert ied Soil Tester(CS )Name CST# <br /> xt r C �U <br /> CST' DD SS Street,City,state,Zi Code) Phone Number, <br /> 7 l,� <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sa�r�I.tary Permit Fee Groundwater ate Iss gent Signator s) <br /> Approved ❑ Owner Given Initial VI � SurchargeFee <br /> VVII CCJJb• Fe jVv <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 />