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(- H {� SANITARY PERMIT APPLICATION GOur�TY <br /> U D■`■ ■R In accord with ILHR 83.05,Wis.Adm. Code STAST�E SANITARY P RM IT# <br /> )3q�e <br /> –Attach complete plans(to the county copy only)for the system, on paper not less thanSTATE PLAN I.D.NUMB�EiR <br /> 8'/2 x 11 inches in size. GO <br /> –See reverse side for instructions for completing this application. PETITION <br /> I. APPLICANT INFORMATION–PLEASE PRINT ALL INFORMATION. Q �7 FOR VARIANCE ❑VES ❑ NO <br /> PROPERTYRWtNER� , 1 OQ V10 r..r /.o CRO,PE%4 LOCM1/ �/ T3 /, N, R �rT ro W <br /> PROPERTY OWNER'S MAILING ADDRESS_ K/ LOT NUMBER,/ BLOCK NUMBER SUBDIVISION NAME <br /> AT. STATE /f ZIP CODE PIJONE NUMBER CITY NEAREST ROA R LANDMARK <br /> n e.4 x `.1 f / i D/� r O VILLAGE : 1W..4 ae, �L.. <br /> II. TYP OF BUILDING OR USE SERVED: Ll <br /> CY <br /> Number of Bedrooms if 1 or 2 Family OR ❑ Public (Specify): <br /> 111. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) <br /> 1. a. ❑ New b.9 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.ln Conventional b. ❑ Alternative C. ❑ Experimental <br /> 2. a. ❑System- b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e.N1 Mound f. ❑ IGP <br /> In-Fill Tank <br /> V. ABSORPTION SYSTEM INFORMATION: (Check one) <br /> 1. a. ❑ Seepage Bed b. NA <br /> LAI 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 IS uare Feet): PROPOSED(Square Feet): <br /> $/r_ Feet 1e 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 xistin Gallons Tanks Concrete glass App. <br /> Tanks Tanks structed <br /> Septic Tank or Holdin Tank ❑ ❑ ❑ <br /> Lift Pum Tank/Si hon Chamber — 6 - s ❑ ❑ <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' Si atur No Sta ps) MP/MPRSW No.: Business Phone Number: <br /> e� �iOiPl � 7/5— y7 3jr <br /> Plumber's dre s(Street,City,State,Zip Code): �" Na.0 D igner: A <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Test r(CST)Name ,,((- CST# / _ <br /> ", Su R.r S / ,,e 1 b 1 <br /> CST's ADDRESS treet,City,State,Zip Code) Phone Number: <br /> uc& �tJ sc, �YFi 7/.1— y7J .�73-5— <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved <br /> SamLary Permit Fe Groundwater ate Issuin ent Signature J:No St amps) <br /> Approved ❑ Owner Given Initial urcharge F0 <br /> Adverse Determination O <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 />