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SANITARY PERMIT APPLICATION OK <br /> 7 DILHR In accord with ILHR 83.05,Wis.Adm.Code <br /> rnobt <br /> ST TE SANITAR PERMIT <br /> jjq— g <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 /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. I FOR VARIANCE ❑YES ❑ NO <br /> PROPERTYOWNER _ PROPERTY LOCATION <br /> t0 R %, S Tge, N, R /5-- E(or <br /> PROPERTY OWNER'S MAILING ADDRESS LOT NUA_PEZR BLOCK NUMBER SUBDIVISION NAME <br /> MAO- LN rJ 2cAn a4 � cs m . <br /> CITY,STATE I ZIP CODE PHONE NUMBER CITY NEAREST ROAD,LAKE OR LANDMARK <br /> EXC l-:L.St O M lV VILLAGE �RZx aOti LE�CN" Ch ` �D <br /> 11. 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. aNew b.XReplacement 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.)gConventional 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. See a e Bed b. ❑Seepage Trench c. ❑ seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 15.SYSTEM ELEVATION 6. WATER SUPPLY: <br /> (Minutes per inch): REQUIRED/(Square Feet): PROPOSED(Square Feet): <br /> / 7/O Feet Private ❑Joint ❑ 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 structed <br /> Septic Tank or Holding Tank 12 i D W� �r -- El ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber I I ❑ ❑ ❑ <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 ature:(N temp _ MPIMPRSW No.: Business Phone Number: <br /> 17> <br /> Plumber's Address(Street,City,State,Zip Code: Name of Designer: <br /> PT yv &ogt­ -7 0I 1 ? <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name - CST# t-16Ah > e Pk t s' <br /> PC lu <br /> Ir <br /> CST's ADDRESS(Street,City,State,Zip Code) Phone Number: <br /> T 1 6 I <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved IS nitary Permit Fee Groundwater ate7­1 Iss Agent Signa re(No Stamps) <br /> Approved ❑ Owner Given Initial 1 O',y-/� Surc�hlarge Fee l <br /> Adverse Determination L� IJLJ or'So� a <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 />