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SANITARY PERMIT APPLICATION COU <br /> DILHR TY <br /> In accord with ILHR 83.05,Wis. Adm. Code (Pat— <br /> S1 (Pat- <br /> S1ATE SANITARY PERMIT# <br /> V790 <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than SI ATE PLAN I.D.NUMBER <br /> 8Yz x 11 inches in size. <br /> —See reverse side for instructions for completing this application. PE TITION <br /> 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES ❑ NO <br /> PROPERTY OWNER p PROPERTY LOCATION <br /> �V 4 / pceA O �ir r PE'N.A)10 %, S o2S �v , N, R /S—11 (or) W <br /> PROPERTY O NER' AILING ADDR S LOT NUMBER BLOCK NUMBER SUBDIVISI N NAME <br /> tie mar 2'fi 0 Ar VA, <br /> CITY, TgTE ` ZIP CODE PHONE NUMBER CITY NEAREST OAD,LAKE OR LANDMARK <br /> peer-r w VILLAGE :WN OF 40 f.A <br /> II. TYPE OF BUILDING 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. El New b. lA Replacement c. ❑ Replacement of d. ❑ Reconnection of e.El 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 Agreem nt to County Copy. <br /> IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2) <br /> 1. a. ®Conventional b. ❑ Alternative C. ❑ Experimental <br /> 2. a. ❑System- b. ❑ Holding c.Ll 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 <br /> T AREA 5.SYSTEM ELEVATION 6. TER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): <br /> 9— 1 o Feet Dqrivate ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in allons Total of Prefab. Fiber- Exper. <br /> INFORMATION New Existing Gallons Tanks Manufacturer's Name Concrete Con- Ste glass Plastic App <br /> Tanks Tanks structed <br /> Septic Tank or HoldingTank .Sd L-r <br /> Lift Pump Tank/Siphon Chamber I E Ej I ❑ ❑ <br /> VII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plan . <br /> Plumber's Name(Print): Plu tier's Signature: No Stamps) MP/Lof <br /> W No.: B siness Phone Number: <br /> Plumber's Address(Street,Ci ate,Zip Code): Name Designer: <br /> 7 <br /> VIII. SOIL TEST INFORMATION <br /> Ce ied oil Tester(CST)Name CST# 4 <br /> 092 <br /> Q r rtL 0 <br /> CST's ADD SS(Street,City,State,ZIP Code) Phone Numter: <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved I Sanitary Permit Fee Groundwater <br /> e <br /> ate_r gnatur �Stamps) <br /> pproved ❑ OwnerDeSurharge Fe <br /> Adverseetermination606 <br /> 0 <br /> ,yr <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,Plumbe <br />