Laserfiche WebLink
I�YDILHR SANITARY PERMIT APPLICATION Co T`'r <br /> In accord with ILHR 83.05,Wis.Adm.Code STA E SANITARY ERMIT# <br /> –Attach complete plans(to the county copy only)for the system, on paper not less than STA E PLAN I.D. MBER <br /> 8'%x 11 inches in size. <br /> –See reverse side for instructions for completing this application. PET TION <br /> 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. Fo VARIANCE ❑YES ❑ NO <br /> PROPERTYOWNER PROPERTY LOCATION <br /> r s�zs ea/ 41e '114,114/'114, S /P T V0, N, R i E (or <br /> PROPERTY OWNER'S MAILING ADDRES9 LOT NU ER BLOCK N-UMBER SUBDIVISIO 4 NAME <br /> CITY ATE ZIP CODE PHONE NUMBE _ VILLAGE : <br /> DQ.Fland NEARQE3T R AD,LAKE OR LANDMARK <br /> TOWN OF <br /> it. TYPE OF BUILDING OR USE SERVED: L <br /> Number of Bedrooms if 1 or 2 Family � 46iny Q225 OR ❑ Public(Specify): <br /> III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) <br /> 1. a. 1�1 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 Agreemei it to County Copy. <br /> IV. TYPEOFSYSTEM: (Check only one in#1 and only one in#2) <br /> r <br /> 1. a.�,l Conventional b. ❑Alternative C. ❑ Experimental <br /> 2. a. ❑System- b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. 11 IGP <br /> In-Fill Tank <br /> V. ABSORPTION SYSTEM INFORMATION: (Check one) <br /> 1. a. gSee a e 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): YSTE _ I'q� <br /> 3 ld Z// 91�.J Feet XP vate El Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> I n allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Stee glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdin Tank — SQ TmG <br /> Lift Pump Tank/Siphon Chamber, ❑ 11 ❑ <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 SpsI MP/MPRSW No.: Bu iness Phone Number: <br /> 3�l /S Plvls-7��?0 <br /> Plumber's Address(Street,City,State,Zip Code): Name of Designer: <br /> cb3rei kill sV�gs 7 W/2Y& /40GAi <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tesler(CST)Name <br /> /s/0/m O <br /> CST's ADDRESS(Street,City,State,Zip Code) Phone Number: <br /> e, 31inr I 60F9Zf /S plvly -7,24.r <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee I Groundwater I�� Issui A nl Si nat r No Stamps) <br /> proved ❑ Owner Given Initial Ofd charge(Fe(e� <br /> Adverse Determination OlJ a5, <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 />