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SANITARY PERMIT APPLICATION D rr <br /> T UILHR In accord with ILHR 83.05,Wis.Adm. Code <br /> STATE/S'ANITARY RMITif <br /> 01 <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than `LA R <br /> Y P P STATE PLAN I.D.NUMBER <br /> 8'%x 11 Inches In size. <br /> —See reverse side for Instructions for Completing this application. P1 TITION <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. F R VARIANCE ❑YES ❑ NO <br /> PROP RTYOWNER PROPERTY LOCATION <br /> nefh rc2�k shad/ E '%k`4 %, S T VO, N, R J E (o r),10 <br /> PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISI N NAM <br /> ,to,C ,Box o?30 8 -- — fere /JeS <br /> CITY,STATE .- / ZIP CODOWN OF, <br /> PHONE NUMBER CITY NEAREST OAD,LAKE OR LANDMARK <br /> E//3worih, W� O� '716-)-773- ❑ VILLAGE: <br /> 11. TYPE OF BUILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family a be�rc�r>s OR ❑ Public(Specify): <br /> 111. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) <br /> 1. a. 9 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 Agreemc nt to County Copy. <br /> IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2) <br /> 1. a. Ix Conventional 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. XSeepage Bed b. ❑Seepage Trench c. ❑ See a e Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(`S/quare Feet): <br /> 010 9v ? Feet ^P ivate ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in al Ions Total #of Manufacturer's Name Prefab. Con- Ste I Fiber- plastic Exper. <br /> INFORMATION New xisting Gallons Tanks Concrete glass App. <br /> �Tfanks Tanks structed <br /> Septic Tank or Holding Tank 7S0 ❑ <br /> Lift Pum Tank/Si hon Chamber 11 1 ❑ ❑ <br /> VII. RESPONSIBILITY STATEMENT <br /> 1,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 mps MP/MPRSW No.: Business Phone Number: <br /> ulade tal,751A011n 3317/ 7/S Plolo- ;U;140 <br /> Plumber's Address(Street,City,State,Zip Code): Name of Designer: <br /> q �?Se.Gs/ci u/I �f 3 klaa� Pr�sir� <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name EPhonne��Number: <br /> I.tlC1n(° ,2u� rn CST's ADDRESS(Street,City,State,Zip Code) <br /> �5 &I651ei, W,,r Colo 7�P17 <br /> IX COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved S.arniitary Permit Fee Groundwater ale Issu' g gent Si natu Stamps) <br /> Approved <br /> E] Owner Given Initial \ill QF'�m I`M\ Surcharge Fee <br /> Adverse Determination 17 OL/ ll V '� q <br /> X. COMMENTS/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Ori,final to County,One Copy To:Bureau of Plumbing,Owner,Plumber <br />