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SANITARY PERMIT APPLICATION G UNTY <br /> ILPALHR <br /> _ In accord with ILHR 83.05,Wis.Adm.Code �U <br /> SATE SANITARY PERMIT <br /> ia61 - <br /> -Attach complete plans(to the county copy only)for the system, on paper not less than S rATE PLAN I.D.NUMBER <br /> 8'/s x 11 inches in size. <br /> —See reverse side for instructions for completing this application. P TITION <br /> 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. IF R VARIANCE ❑YES ❑ NO <br /> PR PERTY OWNER PROPERTY LOCATION <br /> . b r r a K) Sw '/a S w %, S S T4/6, N, R $' Q (or) <br /> PROPERTY OWNER'S MAILING AD ESS LOT NUMBER BLOCK NUMBER SUBDIVIS ON NAME <br /> U s os oc r4 , �' I9 N ocf � La" V,I �j <br /> CITY,,STAT*E ZIP CODE PHONE NUMBER CITY NEAREST ROAD,LAKE OR NDMARK <br /> 1 W /N• M n- 55a8. ❑ VILLAGE : Jac- Ao x1 -C' CT r•`e <br /> 11. TYPE OF BUILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family I 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 t ❑ 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 Agreem ant to County Copy. <br /> IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2) <br /> 1. a. r5konventionai 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. ® Seepage Bed b. ❑Seepage Trench C. ❑ Seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. TER SUPPLY: <br /> (Minutes per inch): REOUIR D(Square Feet): PROPOSED(Square Feet): (�/� �/ ff�� <br /> 3 Q V 31- 9?6r / Feet [Y I rivate EJ joint El Public <br /> VI. TANK CAPACITYin allons Total #of Prefab. Site Fiber- Exper. <br /> INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdin Tank TO ) �. <br /> Lift Pum Tank/Siphon Chamber ❑ ❑ <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) MP/MPRSW No.: B siness Phone Number <br /> I : <br /> PlumberAddress(Street,City,State,Zip Code): Name of Designer: <br /> VIII. SOIL TEST INFORMA ION <br /> Certified S 11 Tester(C T)Name CST# <br /> 0 7 <br /> CSV,kT's AD RESS(Street,City,State,Zi Code) Phone Number <br /> 7`- <br /> JX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee Groundwater ate Iss g ant S gnatur Stamps) <br /> Approved ❑ Owner Given Initial JC/ / /q'7l S oha���Fee� )', '-1G <br /> Adverse Determination Vv' cc 'T OS o_ _ <br /> X. COMMENTS/REASONS FOR DISAPPROVAL: loe <br /> SBD-6398(formerly Plb-67)IF 03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumbs <br />