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D�LHR SANITARY PERMIT APPLICATION co NTY <br /> In accord with ILHR 83.05,Wis.Adm.Code vP A p <br /> STATE SA7A7 PERMIT# \ <br /> I <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBER <br /> 8'%x 11 inches in size. <br /> -See reverse side for instructions for completing this application. PETITION <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. I FOR VARIANCE ❑YES ❑ NO <br /> PROPERTYOWNER PROPERTY LOCATION <br /> m t k' SQOf-f— S E '/s V6'/a, S - T �d, N, R �6 <br /> PROPERTY OWNER'S Mq(LING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME <br /> 7C) Pi-c4 w0dd ✓Q <br /> CITY,STATE / ZCIP—CODE PHONE NUMBER CITY t/1 / NE <br /> APEST ROAD AK / R LANDMARK <br /> ow 3k-1 'I� kwn Jr// �p( POTOWN O VILLAGE .eela,d �D /� <br /> II. TYPE OF BUILDING OR USE SERVED: <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. ❑ 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. ❑Conventional b. �d Alternative C. ❑ Experimental <br /> 2. a. ❑System- b. tK Holding c.❑ Pit Privy It. ❑ Vault Privy e. ❑ Mound f. ❑ IGP <br /> In-Fill Tank <br /> V. ABSORPTION SYSTEM INFORMATION: (Check one) <br /> 1. a. ❑ Seepage 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): PIA <br /> /�/] Feet IpJ IryI' <br /> /� /T Private ❑Joint ❑ Public <br /> CAPACITY <br /> VI. TANK n allons Total #oi Prefab. Site Fiber- Exper. <br /> INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks structed <br /> Se tic Tank roldin TanO _X+ I ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ ❑ <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 bar's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> e(s Kovr e- /11P S-7,f-tj p eS bic6 Vie <br /> Plumger's Address(Street,City,State,Zip Code): Name of Designer: <br /> 1InK�� IT Z Plo r LcJ/ S su8�i NPS �� <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name CST# <br /> CST'sttADDRESS(Street,City,Slate Zip Code) Phone Number: <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee j Groundwater ate Issuing A nt Signature(No Stamps) <br /> Approved ❑ Owner Given Initial Surcharge Fee <br /> Adverse Determination V'" Pik' +11L, L <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 />