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SANITARY PERMIT APPLICATION COU 4TY <br /> 1ZY DILHR In accord with ILHR 83.05,Wis. Adm. Code STA ESANITARYP RMIT# <br /> (0 13 5 <br /> -Attach complete plans(to the county copy only)for the system, on paper not less than STA E PLAN I.D. MBER <br /> 8%x 11 inches in size. <br /> -See reverse side for instructions for completing this application. PET TION <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES ❑ NO <br /> PROPERTY OWNER PROPERTY LOCATION <br /> ger S sw t/4 NE'/4,S 7 T yO, N, R / 4F(or)W <br /> PR PERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISIO NAME <br /> A o l 3 8 a 7 VA lQ6Ur r 00 I <br /> CITY,STA E ZIP CODE PHONE NUMBER LJ CITY / NEAREST ROAD,LAKE OR LANDMARK <br /> El VILLAGW TOWN E : V 4/ M K V `G7 W ,r t t' h <br /> It. TYPE OF 6UILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family OR ❑ Public(Specify): <br /> III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) <br /> 1. a. IX 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 Agreemei it to County Copy. <br /> IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2) <br /> 1. a. Wconventional b. ❑Alternative c. ❑ Experimental <br /> 2. a. ❑System- b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. 11 IGP <br /> In-Fill Tank <br /> V. ABSORPTION SYSTEM INFORMATION: (Check one) <br /> 1. a. seepage Bed b. ❑ See a e Trench c. ❑ Seepage Pit <br /> 2. PERCOLATION RATE 13. ABSORPTION AREA 14. ABSORPTION AREA 15.SYSTEM ELEVATION 6. WrERPPLY:(Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): Feet ❑ ❑Joint -1 Public <br /> VI. TANK CAPACITY Site <br /> in aI'T Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Stee glass Plastic App <br /> structed <br /> Tanks Tanks <br /> Septic Tank or Holding Tank 7St1 � M L <br /> Litt Pump Tank/Siphon Chamber ❑ ❑ F1 <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): Plum is Signature: No Stamps) MP/MPRSW No.: Bu iness Phone Number7�0 4y : <br /> V�L k Q Q o r xr- Q66 -yiJ <br /> Plumber's Address(Street,City,State,zip code): Name of Designer: <br /> lv S <br /> VIII. SOIL TEST INFORMATION <br /> Cer ifled SPil Tester(/CAST)Name CST# <br /> CS 's ADDR SS(Street,City,State,Zip Code) Phone Numb r: <br /> W ZF17`r- w ' S L 96 6 - Vl r,7 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee Groundwater ate Iss n gent Si natur oStamps) <br /> Surcharge Fee <br /> Approved ID Owner Given Initial Cry .,Mn1p <br /> Adverse Determination �(� L�lJ :Js <br /> X. COMMENTS/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Pib-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To.Bureau of Plumbing,Owner,Plumber <br />