Laserfiche WebLink
D'R SANITARY PERMIT APPLICATION COUNTY <br /> In accord with ILHR 83.05,Wis. Adm. Code <br /> I. I ��.e.� SATE SANITARY PERMIT# <br /> —Attach complete plans(to the county copy only)for the system, on paper not less than S ATE PLAN I.D.NUMBER <br /> 8Yz x 11 inches in size. <br /> -See reverse side for instructions for completing this application. <br /> PI rlrloN <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES ❑ NO <br /> PROPERTY OWNER PROPERTY LOCATION <br /> '/4 '/4, S T ` , N, R E (or) W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISI ZNj4AME <br /> CITY,STATE ZIP CODE PHONE NUMBERM CITY NEAREST 3OAD,LAKE OR LANDMARK <br /> D VILLAGE <br /> F-1 TC)WN OF <br /> If. 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 nt to County Copy. <br /> IV. TYPE OF SYSTEM- (Check only one.in#1 and only one in#2) <br /> 1. a. QConventional b. El 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. ❑ seepage Bed b. ❑seepage Trench c. ❑ See a e Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 15.SYSTEM ELEVATION 6. VY IXTER SUPPLY: <br /> (Minutes per inch): REQUIRED(SgtuareFeeo: PROPOSED(Square Feet): <br /> Feet ❑ rivafe ❑Joint ❑Public <br /> VI. TANK CAPACITY Site <br /> in (Ions. - Total #of Prefab. Fiber- Expp. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- St 1 gloms ,Plastic App <br /> Tanks Tanks , structed <br /> Septic Tank or Holding Tank <br /> Lift Pum Tank/Si hon Chamber F-] ❑ <br /> VII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plan . <br /> Plumber's Name(Print): Plumber's Signature:(No Stamps) MP/MPRSW No.: B isiness Phone Number: <br /> Plumber's Address(Street,City,State,Zip Code): Name of Designer: <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 Issuing Agent S gnature(No Stamps) <br /> F-1ApprovedGiven Initial <br /> Approved Surcharge Fee <br /> ❑ <br /> Adverse Determination <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,Plumbe <br />