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II mommill <br /> ^^ SANITARY PERMIT APPLICATION COUNTY - <br /> ID'I`II'711"f In accord with ILHR 83.05,Wis. Adm.Code STATE SANITARYP MIT�# <br /> –Attach complete plans(to the county copy only)for the system, on paper not less than STATE PLAN I. .NUMBER <br /> 8%x x 11 inches in size. <br /> –See reverse side for instructions for Completing this application. PETITION <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> FOR VARIANCE ❑YES ❑ NO <br /> PR ERTY OWNER PROPERTY LOCATION ./ <br /> , Oji%cl /7V 1712 '/4 t/4, S .3�F T 39, N, R / E (or <br /> PROPERTY OWNER'S MAILING ADDRESS LOT NUj.4�R BLOCK NUMBER SUBDIVISION NAMES m �� <br /> CITY,STItT�� ZIP CO E' PHONE NUMBER S CITY � NEAREST ROA KE O_ R LANDMARK <br /> F/al,C•YL/T/F� J �S Or/O/71 VILLAGE : eC!/ <br /> II. TYPE OF BUILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family a ZA2AQYYtS 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. LlReplacement c. ElReplacement of d. ❑ Reconnection of e.F-1Repairof 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. ❑Conventional b. KAlternative 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. ❑ 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): REQUIRED(Square Feet): PROPOSED(Square Feet): <br /> Feet Private ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> 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 q strutted <br /> Se tic Tank or Holding Tank O — .coo 05 ��� ❑ ❑ <br /> Litt Pum Tank/Si hon Chamber 1 ❑ ❑ 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): Plumber's Signature: o Stamps) MP/MPRSW No.: Business Phone Number: <br /> klaye_ X310/ 7/s BGG 7�P�o <br /> Plumber's Address(Street,City,State,Zip Code): Name of Designer: <br /> e..S, ei, k/I 9/�3 I c%1pe ,t°u�Jholrn <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name CST q V3 <br /> Allbo <br /> CST's ADDRESS(Street,City,State,Zip Code) Phone Number: <br /> kllf%/ei, /„I NS 1 7/5 )-96& —V1,57 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee Groundwater ate Issuing Agent Signature(No Stamps) <br /> Approved ❑ Owner Given Initial S rcase F� <br /> Adverse Determination ` 11....�� 3 3i fa <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 />