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(� SANITARY PERMIT APPLICATION COD Y <br /> L7, DILHR In accord with ILHR 83.05,Wis.Adm.Code <br /> STATE SANITARY ERMIT# <br /> i ag <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 /> PROPERTY OWNER _}.. PROPERTY LOCATION <br /> a^,� L I rw Yr ( kJC '/4 SLl '/4, S '7 T C , N, R /JA (or) W <br /> PROPERTY OWNER'S AILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISIONNAME <br /> 4' 14 <br /> CITY,STATE ZIP CODE PHONE NUMBER CITY F)l NEAR ROAD,LAKE OR LANDMARK <br /> 0 VILLAGE : �� 9 J C ` l B H9t E� <br /> S 999 <br /> 11. TYPE F BUILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family r� 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. 11 Replacementof d. LlReconnection 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. Conventional b. ❑ Alternative C. ❑ Experimental <br /> 2. a. ❑System- b. ❑ Holding c.El Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP <br /> In-Fill Tank <br /> V. ABSORPTION SYSTEM INFORMATION: (Check one) <br /> 1. a. M Seepage Bed b. ❑ See a e Trench C. ❑ See a e Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM E IEVAATIIQN 6. WATER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): / / 1 \\lI <br /> v, <br /> Feet 0Private ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in alloT Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks structed <br /> Septic Tank or Holding TankS c 1 7 A4 L <br /> Lift Pump Tank/Siphon Chamber —Li ❑ ❑ ❑ ❑ ❑ <br /> VII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Plu Der' Name(Print): Plumber's Signature:(N Stam s) MP/MPRSW No.: Business Phone Number: <br /> jJ <br /> We d�e r, c h G C S j �� ° / , <br /> Plumber's Address(Street,City,State,Zip Code): N,"e of Designer: <br /> VIII. SOIL TEST INFORMATION <br /> CertifiedSoil Tester(CST)NameCST# <br /> �� .. <br /> l�'c 4 V ill'( "' C <br /> CST's ADD SS(Scree,City,Slate, p Code) Phone Number: <br /> W S' y F 3`S FAF. ' g1J 7 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee Groundwater ate Is g Agent Si lure Stamps) <br /> Approved ❑ Owner Given Initial ��,,,,((�� /qSurcharge Fee <br /> Adverse Determination `W-W OD J <br /> X. COMMENTS/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)IF,03/86) DISTRIBUTION: Original to County,One Copy To.Bureau of Plumbing,Owner,Plumber <br />