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SANITARY PERMIT APPLICATION C NTV <br /> � DLLHR In accord with ILHR 83.05,Wis.Adm. Code r <br /> _ ST TE SANITARY RMIT# <br /> C �7 D�,- <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than ST TE PLAN I.D. BER <br /> 8'h x 11 inches in size. <br /> —See reverse side for instructions for completing this application. P ITION <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. F R VARIANCE ❑YES ❑ NO <br /> PROPERTY OWN n PROPERTY LOCATION <br /> ,41, � ^r7 Ifo 6— AJW'/aSW %, S 3� T V/, N, R 16 F(or) W <br /> PROPERTY OWNER'S MAILING A DRESS LOTNUMBER I BLOCK NUMBER SUBDI'VIISI NNAME <br /> g.) e W L� ( czq d S7' AIA VA `'t <br /> /V <br /> CITY,STATE ZIP CODE PHONE NUMBER CITU c+ NEAREST OAD,LAKE OR LANDMARK <br /> [/LAY <br /> 8 L VTOWN OF <br /> ILLAGE: tl W l ��' G / <br /> II. TYPE OF BUILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family a 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. S1 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. Y Seepage Bed b. ❑seepage Trench C. ❑ Seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 15.SYSTEM ELEVATION 6. IN TER SUPPLY: <br /> (Minutes per inch): REQUIRE quare Feet): PROPOS( Square Feet): <br /> d-- f11��J1 q d— �' p Feet [Orivate ❑Joint [:] Public <br /> VI. TANK CAPACITY Site <br /> in aallons 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 /> Se tic Tank or HoldingTank 1.1'0 SO T L ❑ ❑� 11ElPum 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): Plumber's Signature No Stamps) MP/MPRSW No.: B siness Phone Number: <br /> AD o- J�P« F fKr g' a 30 - /s F66 -V13--7 <br /> Plumber's Address(Street,City,Stale,Zip Code): Name of Designer: <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name EPhone <br /> LIZ v �pr 'c )AQ y f S/ <br /> CST's ADDRESS(Street,City,State, p Code) EE ers � r ltii _ p66 Y/S-7 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> `1�A' ❑ Disapproved Sanitary Permit Fee Groundwater ate Issu Agents n lure(No Stamps) <br /> L*Approved ❑ Owner Given Initial Frr-� Surcharge Fee I' _ <br /> /// ��\ Adverse Determination vv <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 />