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J DI R SANITARY PERMIT APPLICATION oo "TY <br /> In accord with ILHR 83.05,Wis. Adm. Code <br /> Ap•es^•,e.,,,,�,�.,w� STATE SANITARY PERMIT# <br /> W (6 , Z102) <br /> -Attach complete plans (to the county copy only)for the system,on paper not less than STATE PLAN 1.0-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. FOR VARIANCE ❑YES ❑ NO <br /> PROPERTYOWNER PROPERTY LOCATION �/ <br /> S F_ '/4S(y'/4, S TyQN, R / yjZ (or) W <br /> PROPERTY OWNER'S AILINGAODRESS LOTNUMBER BLOCKNU BER SUBDIVI IOU <br /> ONAME <br /> CITY,STATE ZIP CODE PHONE NUMBER CITY NEAREST ROAD,LAKE OR LANDMA K <br /> t 'C VILLAGE : �` # <br /> i { — <br /> I1. 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. 119 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. ® Seepage Bed b. ❑seepage Trench c. ❑ Seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 15.SYSTEM ELEVATION 6. WATER SUPPLY: <br /> (Mi utes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): o q Iq <br /> 3 �— / �. / Feet A Private ❑Joint ❑ Public <br /> VI. TANK CAPACITYin allons Total #of Prefab. Site Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks structed <br /> Septic Tank or Holding Tank tyC El ❑ El ❑ <br /> Lift Pump Tank/Siphon Chamber 1 ❑ ❑ ❑ ❑ <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:(Ne Stamps) MP/MPRSW No.: Business Phone Number: <br /> %4"C3 -yis 7 <br /> lumber'sdress(Street,City,StAte,Zip Code): Name of Designer: <br /> wF Sy8f3 <br /> Vlll. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name CST# <br /> i s o � <br /> CST's ADDRESS(Street,City, tat Zip Code) Phone Number: <br /> 7—r- W , S 9 l S 46- 9rl3q <br /> X. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved I Sanitary Permit Fee GroundwaterMt Si ure(No Stamp <br /> ate Is) <br /> NP Adverse <br /> ❑ Owner Given Initial CQS�urcharge FFeee, <br /> Adverse Determination �O( I"" '"�' /"v 741 <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 />