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SANITARY PERMIT APPLICATION COUNTY <br /> C� QILHR In accord with ILHR 83.05,Wis. Adm. Code <br /> STATE SANITARY P RMIT# <br /> �I <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.ROMBE <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 /> PROPERTYOWNER PROPERTY LOCATION <br /> &o (-/ le. Fa1xrrn kf tl'/< �EY4, S 7 T SAO, N, R /�7 E (or&11 <br /> PROPERTY OWNER'S MAILING ADDRESS LOTNU BER BLOCK NUMBER SUBDIVISION NAME <br /> /721i?12CA Zha. AVC.� �p /s ATE m.(1 Z�S PHONE CITY :�/Qn� NEAREST Lo,UC./ N�c.t. c <br /> .P� ILLAGE : LC G/OW .C.-i <br /> If. TYPE OF BUILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family aR ❑ 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 G. ❑ 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## q134 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. TYPEOFSYSTEM: (Check only one in#1 and only one in#2)ta <br /> 1. a. Conventional b. El Alternative C. Experimental <br /> 2. a. /❑System- b. ❑ Holding C.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound I. ❑ IGP <br /> In-Fill Tank <br /> V. ABSORPTION SYSTEM INFORMATION: (Check one) <br /> 1. a. 9Seepage Bed b. ❑Seepage Trench c. ❑ seepage 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(Squ re Feet): Q <br /> T/Q 'r`/ / •9 Feet Private ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in allons Total Lof <br /> Manufacturer's Name Prefab. Con- Steel Fiber- plastic Exper.INFORMATION New xisting Gallons Concrete glass App. <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank 7So T C— El El <br /> ❑ ❑ <br /> Lift Pum Tank/Siphon Chamber ❑ ❑ Li ❑ 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:(No Stamps MP/MPRSW No.: Business Phone Number <br /> vlade Z&7G/-)0/,-, : <br /> h0/m �� 33Cv/ 7/.5 kt,Co- 7-??42 <br /> Plumber's Address(Street,City,State,Zip Code): Name of Designer: <br /> a(oV5D T�ouf.4ve. 3, o. �ro?as ) fey lt/Is/ dc%1pe �uu�JhO/m <br /> Vlll. SOIL TEST INFORMATION <br /> Certified Soil Tester( ST)Name CST# <br /> �,L/Qde ,�uh0/m 353 <br /> CST's ADDRESS(Street,City,State,Zip Code) Phone Number: <br /> game ( 7s �Glo -7�?Ply <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved S nitary Permit Fee I Grountlwater ate Iss gA nt Signature Stamps) <br /> Approved ❑ Owner Given Initial J(�/�, �/��(7�) S charge F/�a (nJ <br /> Adverse Determination SD,( 35_rGD —/' t� <br /> X. COMMENTS/REASONS FOR DISAPPROVAL: <br /> a <br /> SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber <br />