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SANITARY PERMIT APPLICATION D NTY <br /> (�I DJLHR In accord with ILHR 83.05,Wis.Adm.Code ur <br /> j� c4s_tli S ATESANITARY/PERMIT# <br /> MEN i-� <br /> —Attach complete plans(to the county copy only)for the system,on paper noless than `j S ATE PLAN I.D.NUMBER <br /> 8'h x 11 inches in size. I l _ <br /> —See reverse side for instructions for completing this application. & S r' j C��j <br /> Lt P TITION <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. F R VARIANCE ❑YES ❑ NO <br /> PROPERTY OWNS PROPERTY LOCATION S" <br /> tC- r n / f o SE '/a Ste '/4, S VT1f9VN, R l rp(or)W <br /> PROPERTY OWNER'S MAILING ADDRESS/ LO,NUMBER BLOCK NUMBER SUBDIV�$ON NAME <br /> t7 L,..-.eST r /'t J NAC, /",/'lC t <br /> CITY,STAT/E/ ZIP CODE PHONE NUMBER CITY NEAREST R}O�AD,LAKE OR?NDMARRK <br /> QS tv 4!Y .S'S'1/ (a/1, f _/fI VILLAGE: 7yCtSOn /EJ 3 , k SG/r. 0 44R <br /> IL 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. ❑ 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 Agreem ant to County Copy. <br /> IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2) <br /> 1. a. [A Conventional 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 /> /� r4 <br /> 1. a. ® See a e ed 1'� b. ❑Seepage Trench c. ❑ seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 14. ABSORPTION AREA 5.SYSTEM ELEVATION 6. AATER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): <br /> Feet ❑ rivate []Joint El Public <br /> VI. TANK CAPACITY Site <br /> In allons Total #of Manufacturer's Name Prefab. Con- Steat Fiber- plastic Exper. <br /> INFORMATION New xistin Gallons Tanks Concrete glass App. <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank CCC ) Lr1 C"' 0 11 ❑ <br /> Lift Pu mp Tan k/S 1p hon Chamber 7 SO 1 t W C. ❑ <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): Plu is Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> o ij�e V c Nests 6 3 0 y is �6(�- <br /> Plumber's Addre s( reet,Cit ,Slate,Zip Code): N of D signer: <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name CST# <br /> CST's ADDRESS(Street,City,State,Zip Code) Phone Num er: <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee Groundwater ate uin Agent ign re IN Stamps) <br /> Approved ❑ Owner Given Initial �1 //��,,��� S charge Fgee(� p� Q� <br /> Adverse Determination 6o.Cb CIO O <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 />