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SIL MMN SANITARY PERMIT APPLICATION COUNTY <br /> In accord with ILHR 83.05,Wis.Adm. Code <br /> STATE SANITARY ERMIT# <br /> a <br /> –Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NU <br /> pMBER <br /> 8'%x 11 inches in size. O O <br /> –See reverse side for instructions for completing this application. PETITION <br /> I. APPLICANT INFORMATION–PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES ❑ NO <br /> PR PERTY 07IR / / PROPERTY LOCATION <br /> f k C G c /7� a� Ya, S o20 T �QN, R IV I(or) W <br /> P OPER^ WONER'S MAI ING ADDRES / LOT NUMBER BLOCK NUty1BER SUBDSIQN NAME <br /> tip <br /> ji <br /> CITY,ST TE ZIP CODE PHONE NUMBER CITY NEAREST ROAD,�AI()<OR L�NDfAARK <br /> A n4 A - f O VILLAGE : \ C� / �� <br /> H. TYPE OF BUILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family .l— 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. 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. XConventional b. ❑ Alternative C. ❑ Experimental <br /> 2. a. ❑System- b. WHolding c.Ll Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP <br /> In-Fill Tank <br /> V. ABSORPTION SYSTEM INFORMATION: (Check one) <br /> 1. . ❑ See a e Bed b. ❑Seepage Trench c. ❑ Seepage Pit <br /> 2. P RCOLATION RATE 3. ABSORPTION AREA N AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: <br /> inutes per inch): REOUI re eet): PROPOSED(Square �.__ __ <br /> Feet ivate ❑Joint El Public <br /> VI. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdin Tank 0 Q ID LlLitt Pum Tank/Si hon Chamber ELI ❑ ❑ <br /> VII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plans. <br /> PI ber' Name(Print): PI 's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> 6i�1<< asp 6 lr -I <br /> Plumber's ddress(Street,Citt,State,Zip Code): Namesig er: 1 <br /> w S <br /> VIII. SOIL TEST INFORMATION IV <br /> Certi� dTester(CS 7) me CST# <br /> If <br /> n�C <br /> CST's ADDRESS(s}�et,City,State, ip ode) Phone Number: <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee Groundwater ate Issuing Agent Signature(No Stamps) <br /> Approved ❑ Owner Given Initial (�p)�} S rcharge as <br /> Adverse Determination 6�•— " <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 />