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SANITARY PERMIT APPLICATION COUNTY <br /> (�I DILHR In accord with ILHR 83.05,Wis.Adm.Code <br /> STATE SANITARY PE MIT# <br /> L <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.N BER <br /> 81/z x 11 inches in size. <br /> —See reverse side for instructions for completing this application. <br /> PETITION <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES [ANO <br /> PROPERTY OWNER tPROPERTY LOCATION <br /> ]� P6, S / T , N, R E ( W <br /> PROPERTY OWNER'S MAILING ADDRESS UMBER BLOCK NUMBER SUBDIVISION NAME <br /> GSM vCITY,STATE ZIP ODE PHONE NUMBERY NE EST ROAD,LAKE OR LANDMARK <br /> G L�pLAGE : PZZ .O <br /> II. TYPE OF BUILDING OR USE SERVED: G <br /> Number of Bedrooms if 1 or 2 Family 3 OR ❑ Public(Specify): <br /> III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) <br /> 1. a. Idl 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. X 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 /> 1. a. XSeepage Bed b. ❑ Seepage Trench c. ❑ Seepage Pit <br /> 2. PERCOLATION RATE 3, ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): Q Fye <br /> 6i �5 / Feet XPrivate ❑Joint ❑ Public <br /> VI. TANK CAPACITY <br /> in allons Total #of Prefab. Site ]Fiber- Exper.INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel lass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or HoldingTank /000 Afd ❑ ❑ ❑ <br /> Lift Pum Tank/Si hon Chamber 0 y ❑ ❑ ❑ <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 er's ign e:(No mps) MP/MPRSW No.: Business Phone Number: <br /> aBC .c 3 8 <br /> Plumber's Address(Street,City,State,Zip Cod`15): Sy� Name of Designer: <br /> le /5/ N. lrs i 5 u. ~ <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name CST# <br /> A/Y1 G S ,U !' 9Q <br /> CST's ADDRESS(Street,City,State,Zip Code) Phone Number: <br /> " S 164,21k A <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee Groundwater ate Issuing Agent Signature(No Stamps) <br /> A roved ❑ Owner Given Initial (r��j/�� Surchargetseje� (n', <br /> pP Adverse Determination 0-i <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 />