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SANITARY PERMIT APPLICATION COUNT <br /> C DILHR Y <br /> In accord with ILHR 83.05,Wis.Adm. Code <br /> STATE SANITARY PERMIT# <br /> —Attach complete plans(to the county copy only)for the system, on paper not less than STATE PLAN I.D.NU BER <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 ❑YES ❑ NO <br /> PROPERTY OWNER PR PERTYY LOCATION <br /> o cc F OX�4 y2 4, S J& T moo, N, R / Mor <br /> PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME <br /> AxAlk oZ /Y.R I/A <br /> CITY,STATE ZIP CODE PHONE NUMBER CITY NEAREST ROAD,LAKE OR LANDMARK <br /> T. % V D O VILLAGE : vTT 6 c L <br /> If. TYPE OF BUILDING OR USE SERVED: 7 <br /> Number of Bedrooms if 1 or 2 Family J OR ❑ Public(Specify): <br /> III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable)EO <br /> 1. a. L'J 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 /> 1. a. ®'Conventional b. ❑ Alternative c. ❑ Experimental <br /> 2. a. ❑System- b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound I. ❑ IGP <br /> In-Fill Tank <br /> V. ABSORPTION SYSTEM INFORMATION: (Check one) <br /> 1. a. See a e Bed b. ❑ Seepage Trench C. ❑ See a e Pit <br /> 2. PERCOLATION RATE 3, ABSORPTION AREA 14. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): <br /> , 9 Feet =Private ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in gallons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdi no Tank OOU CU ffLt�f�+ 77- ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ <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 <br /> Signature:(No S mps) ,MP/MPRSW No.: Business Phone Number: <br /> eL Cr L sc : Nr C1lc J/ V! 36 to >seb <br /> Plumber's Address(Street,City,State,Zip Code): Name of Designer: <br /> /2 02ZDYe« CAkc GcJ'r. .67YP7/ <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name CST# <br /> cc: .s `5_2 a9 <br /> CST's ADDRESS(Street,City,State,Zip Code) Phone Number: <br /> le 7, L Kc w ' 87 /s - 3>fLo <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sa itary Permit Fee Groundwater ale Iss gent Signal (No Stamps) <br /> Approved ❑ Owner Given Initial �n /y-T� Surc-h�arCge F/e�e-/� / <br /> Adverse Determination ��J V l/ O{�]�VlJ <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 />