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y/�� SANITARY PERMIT APPLICATION COUNTY <br /> U DIL{�■R In accord with ILHR 83.05,Wis.Adm.Code STATE SANITARY P RMIT/j <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D. MBER <br /> 8'/A x 11 inches in size. C, _ C <br /> -See reverse side for instructions for completing this application. sal <br /> PETITION <br /> 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES NO <br /> PROPERTY WNER PROPERTY LOCATION <br /> MC �tq �/�d e jeS l�'/aS�'/n, S .S T .39N, R 1 E (o W <br /> PRO RTY OWNER'S MAILING ADDRESS LOTNUMBER BLOCKfJ4 MBER SUBDIVONNAME <br /> I N*A'T '1Vr <br /> CITY,STATE ZIP COD_ PHONE NUMBER CITY NE ARE T ROAD,LAKE OR LANDMARK <br /> �PlN W �- S` Yr / VILLAGE : I`CN <br /> II. TYPE OF BUILDING OR USE SERVED: � R(d I <br /> Number of Bedrooms if 1 or 2 Family OR IX Public(Specify): �reC) F $ <br /> III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4, if applicable) <br /> 1. a. XNew 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. WAIternative C. ❑ Experimental <br /> 2. a. ❑System- b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f.�4 IGP <br /> In-Fill Tank <br /> V. ABSORPTION SYSTEM INFORMATION: (Check one) <br /> 1. a. XSeepage Bed b. [Iseepage Trench c. ❑ seepage Pit <br /> 2. PERCOLATION RATE F. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): Ips <br /> SV O < � �RFeet tp Private ❑Joint ❑ Public <br /> Q9 <br /> VI. TANK CAPACITY Site <br /> in allons Total #of <br /> Prefab. Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank W r w� ❑ ❑ 11Lift Pum Tank/Si hon Chamber G ❑ r7F-1 <br /> VII. RESPONSIBILITY STATEMENT <br /> 1,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Plumber' Name(Print): P e Si nature:�N tam s) MP/MPRSW No.: Business Phone Number: <br /> 6 861-W<P <br /> tuber's ddre7� St <br /> -s-(Street, ity,Statg,Zip Code):Q Name of Designer: <br /> TG U.)- O <br /> VIII. SOIL TEST INFORMATION <br /> Ce ifie,Q So' Tester(C )Name CST# d <br /> /� <br /> CST's ADDRE (Sir L City,St e,Zip ode) Phone Number: <br /> tt� q4 -oes <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee Groundwater ate Issuing Agent Signature(No Stamps) <br /> Approved F7Owner Given Initial r S charge Fee <br /> Adverse Determination 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 />