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(�, Oa SANITARY PERMIT APPLICATION CCU) <br /> C v <br /> l] ILHA In accord with ILHR 83.05,Wis.Adm. Code U� <br /> STATE SAN ITAR PERMIT <br /> a 13 j g8 <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 ❑YES ❑ NO <br /> PROPERTYOWNER PROPERTY LOC ON <br /> QCJ� �o"oUF/a.Cor /4, S T p , N, R / Wor) W <br /> PROPERTY OWNER'S MAILI G ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME <br /> 2 -2- mvce4 / kR <br /> CITY,STATE ZIP CODE PHONE NUMBER 0 CITY NEAREST ROAD,LAKE OR LANDMARK <br /> 10 VILLAGE:6­1� 10 TOWN OF O `/�T� <br /> 11. TYPE OF BUILDING OR USE SERVED: C <br /> Number of Bedrooms if 1 Or 2 Family OR ❑ Public(Specify): <br /> 111. PURPOSEOFAPPLICATION: (Check only one in#1. Check#2,3 or 4, if applicable) <br /> � <br /> 1. a. LJ 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. P�'Lonventional b. ❑Alternative C. ❑ Experimental <br /> 2. a. ❑System- b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound I. ❑ IGP <br /> In-Fill Tank <br /> V. ABSORPTION SYSTEM INFORMATION: (Check one) <br /> 1. a. [See a e Bed b. ❑Seepage Trench c. ❑ Seepage Pit <br /> 2. PERCOLATION RATE 13. ABSORPTION AREA 14. ABSORPTION AREA 5.SYSTEM ELEVATION ZWATER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): pp <br /> /D 7!D 7J�!9 Feet vate ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xisa Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank /060 IOo Wal cora"7r — ❑ ❑ <br /> Lift Pum Tank/Si hon 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 /> Plumber's Name(Print): Plumber's Signature:(No Stamps) MWMPRSW No.: Business Phone Number: <br /> Plumber's Address(Street,City,State,Zip Code): Name of Designer: <br /> AX A S ,C,[l l cgE i B <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name CST# <br /> C e C ,'/- ,I12,` ,e y�9 <br /> CST's ADDRESS(Street,City,State,Zip Code) Phone Number: <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Ej Disapproved Sanitary Permit Fee Groundwater Date Issuing Agent Signature(No Stamps) <br /> Approved ❑ Owner Given InitialSur�cc"aarcrge Fee <br /> Adverse Determination J � —l� <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 />