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SANITARY PERMIT APPLICATION COU TY <br /> (�I DILHR In accord with ILHR 83.05,Wis.Adm. Code r <br /> mtt— <br /> STATE SANITARY ERMIT# <br /> —Attach complete plans(to the county copy only)for the system, on paper not less than STATE PLAN I.D. UMBER <br /> 8'%x 11 inches in size. <br /> —See reverse side for instructions for completing this application. POTITION <br /> 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES ❑ NO <br /> PROPERTY OWNER PROPERTY LOCATION <br /> h. a , Tnr< �, /VLd'/, VF_ s, S 3.2 T 41QN, R / (o F(or) W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER I SUBOIVISI. N NAME <br /> Fi L4 � wi s s /UA B1' ltl ou/ f Erre ,r <br /> CITY,STATE ZIP CODE PHONE NUMBER CITY NEA ES OAD,LAKE OR LANDMARK <br /> .S 8S 0 VILLAGEF-1 TOWN OF' <br /> : <br /> 11. TYPE OF BUILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family OR ❑ Public(Specify): <br /> Ill. PURPIOppSffE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) <br /> 1. a. IA,I 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 oneowner/building. Attach Common Ownership Agreement to County Copy. <br /> IV. TYPEOFSYSTEM: (Check only one in#1 and only one in#2)LpI <br /> 1. a. 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. ® See a e 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(Square Feet): p <br /> I d '1 <br /> 3 � ! f a Feet ®Private ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in gallons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. <br /> INFORMATION New xistin Gallons Tanks Concrete glass App. <br /> Tanks Tanks strutted <br /> Septic Tank or HoldingTank 7$O ( -r AA C ❑ <br /> Lift Pum Tank/Siphon Chamber 7S V ! /H C_ I ❑ I El ❑ ❑ <br /> VII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plans. <br /> PI b �er's Name(Print): PI er's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number <br /> A : <br /> ,,- ,w ���. 03 os' ? 7AF 966 yrr7 <br /> Plumber's Address treat,City,State,Zip Code): Nam of Designer: <br /> Vlll. SOIL TEST INFORMATION <br /> Certif" d Soil Tester`CST Name CST# ` <br /> o �r I 0 (�S 5 <br /> CST's ADDRE S(Sir et,City,State,Zip ode) Phone Number: <br /> 1,�1-�e..M _ <N- y ae 93 7/a- X66 -5��� 7 <br /> IX COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee Groundwater ate Ias Agent Si ture(No Stamps) <br /> Approved ❑ Owner Given Initial /_h o/Qn Surcgh�e Fee n <br /> Adverse Determination <br /> X. COMMENTS/REASONS FOR DISAPPROVAL: 57 <br /> SBD-6398(formerly Plb-67)IF,03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber <br />