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SANITARY PERMIT APPLICATION CG NTY <br /> 7 0IL' HR In accord with ILHR 83.05,Wis.Adm. Code u f <br /> ' STATE SANITARY PERMIT# <br /> 13o7a <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than STA PLAN I.D. UMBER <br /> 8'%x 11 inches in size. '03� <br /> —See reverse side for instructions for completing this application. PETITION <br /> 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES ❑ NO <br /> PWPERTY OWNEg PROPERTY LOCATION <br /> KQ/ Wan/RS5 SJAI'%Sf-'%, S ;?& T39, N, R /& or� <br /> PROPERTY OWNER'S MAILING ADDRESS LOTNUMBER BLOCKNUMBER SUBDIVISION NAME <br /> y I•i/0000Rvenve 5 <br /> CITY,STATE JZIPCODE PHONE NUMBER LJ CITY NEAREST ROAD,LAKE OR LANDMARK <br /> fire )3w,- / .L-HA/ 5-S 1 /O/a o VILLAGE tWee Ton C/4m La.� <br /> It. TYPE OF BUILDING OR USE SERVED: 1L_� <br /> Number of Bedrooms if 1 or 2 Family a JCC//OOmS OR ❑ 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 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 Agreement to County Copy. <br /> IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2) <br /> El 1. a. Conventional b. Alternative c. ❑ Experimental <br /> 2. a. ❑System- b. X 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. ❑ Seepage Bed b. ❑Seepage Trench C. ❑ Seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 15.SYSTEM ELEVATION 6. WATER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): ,/ F <br /> —��- eet �v1 141.4 AIR A64 ICI Private ❑Joint ❑ Public <br /> CAPACITY <br /> VI. TANK in allons Total #of Prefab. Site Fiber- Exper. <br /> INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks structed <br /> Septic Tank or Holding Tank OODl.f.SCr ele. ❑ ❑ <br /> Lift Pum Tank/Si hon Chamber I ❑ I ❑ I ❑ I ❑ I L ❑ <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 mps MP/MPRSW No.: Business Phone Number: <br /> W&C Rufsho/m 03340/ 7/5- P&4-7-?A& <br /> Plumber's Address(Street,City,State,Zip Code): Name of Designer: <br /> BOX WX 551P9i Wade ,6u)317o1m <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester CST)Name CST# <br /> Wade RUfshdm 00 35P3 <br /> CST's ADDRESS(Street,City,State,Zip Code) Phone Number: <br /> BM -7-2SWICh5fer, WE 54IN3 7/5 )PUP-7-7P4 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved i Sanitary Permit Fee Groundwater ate Issuing A nt Signature(No Stamps) <br /> Approved ❑ Owner Given Initial Surcharge Fee <br /> Adverse Determination <br /> X. COMMENTS/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.03186) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber <br />