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E7E <br /> SANITARYPERMIT APPLICATION Co TY414 In accord with ILHR 83.05,Wis. Adm.Code SATESANITA ZMBER <br /> RMIT# <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I. <br /> 8'%x 11 inches in size. <br /> -See reverse side for instructions for completing this application. PETITION <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. FOR VARIANCE F-1 <br /> YES ❑ NO <br /> ?PROPERTY OWNE PROPERTY LOCATION <br /> N& %A)�'/a, S E 5' Tl/ , N, R /4 EERTY OWNER'S MAILING ADDRESS LOTNUMBER BLOCK NUMBERSUBDIVISION NAME <br /> 5� C1A,psuc� I STATE ZIP CODE PHONE NUMBER CIT NEAREST ROAD LA/�O,,R�—LANDMARK <br /> 14� O VILLAGE: !tom /Il� <br /> II. TYPE OF BUILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family c� OR ❑ Public(Specify): <br /> III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) <br /> 1. a. ew b.❑ Replacement c. ❑ Replacement of d.ElReconnection of e.❑ Repair of an <br /> ystem 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.�4Conventional 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. ❑Seepa e 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(Squar Feet): <br /> /D - Feet Private ❑Joint ❑ Public <br /> VI. TANK CAPACITY Prefab. Site Fiber- Exper <br /> Manufacturer's Name <br /> in al Ions Total #of . <br /> INFORMATION New xistin Gallons Tanks Concrete Con- Steel glass Plastic Appp <br /> strutted <br /> Tanks Tanks ❑ <br /> Septic Tank or Holding Tank 7 T 1147- <br /> Litt ❑ ❑ <br /> Lift Pum Tank/Siphon Chamber <br /> /l G. <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 Si nature:(%Stamps MP/MPRSW No.: Business Phone Number: [ <br /> 507,;k, 7/; �4pf-3Y� <br /> Plumber's Address(Street,City,State,Zip Code): Name of Designer: <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soester(CST)Name CST# <br /> pivr9,C� �iP© <br /> CST's ADDRESS(Stt,City,State,Zip Code) Phone Number: <br /> ) !� / _� �/ �rlQpO ZS/c6_3,"� <br /> R 6 7 L j <br /> IXCOUNTY/DEPARTMENT USE ONLY <br /> /V 17'/ TCU/.l <br /> TF� <br /> isapproved Sa nary Permit Fee Groundwater ate �l �Q Iss gent Signatur o Stampg) <br /> qZ.� Su Fee n��7 CID <br /> ApprovewnerGiven Initial Oldverse Determination <br /> X. COMMENTS/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber <br />