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�IL1-IR SANITARY PERMIT APPLICATION CPUXTY <br /> In accord with ILHR 83.05,Wis.Adm. Code <br /> '��""'�'�'•�` <br /> STATE SANITARY PERT/# <br /> � <br /> MI <br /> —Attach complete plans (to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBERCJ� <br /> 8'h x 11 inches in size. <br /> —See reverse side for instructions for completing this application. P TITION <br /> i. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. F R VARIANCE ❑YES [] No <br /> PROPERTY PROPERTY LOCATION <br /> a& '/a, S 12 T //� N, R 6 E (or W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVIS N NAME <br /> CITY,STATE ZIP CODE PHONE NUMBER CITY NEAREST CAD,LAKE OR LANDMARK <br /> S G , /✓I/1 , $5/O (u/a (l 2fr VILLAGE D /GCq CC IZC�AI� <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,it applicable) <br /> 1. a. ❑ New b. Replacement c. ElReplacement 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. NConventional 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. ee a e 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(S/quare Feet): PROPOSED(Square Feet): <br /> 1 Feet R rivate [ Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in gal ons Total #of Manufacturer's Name Prefab. Fiber- plastic Exper. <br /> INFORMATION New xisting Gallons Tanks Concrete Con- Ste I glass App. <br /> Tanks Tanks structed <br /> Septic Tank or HoldingTank S�-' nj <br /> Lift Pum Tank/Siphon Chamber I F71 I ❑ ❑ <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): Plyprb9rTS�atur ,:(No Sta ps _ MP/MPRSW No.: Bu iness Phone Number: <br /> cti l7 L , f� _ �j _ -3 A079- 2,- 94- 35-in <br /> Plumber's Address(Street,City,State,Zip Code): Name of Designer: <br /> 3 e Y, el 70 t CJ-3C) L} — <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name CST# <br /> CST's 9DD ESS(Street,City,State,Zip Code) Phone Number <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee Groundwater ate Issuing nt Signature(No Stamps) <br /> TApproved ❑ Owner Given Initial � rcharge/F�e-?e� (��/� <br /> Adverse Determination '.XJ`� r('T - �' <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 />