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�====I SANITARY PERMIT APPLICATION CO NTY <br /> PILMR In accord with ILHR 83.05,Wis.Adm.Code u�ne� <br /> IST TESANITARYP RMIT# <br /> –Attach complete plans(to the county copy only)for the system,on paper not less than ST TE PLAN I.D. MBER <br /> 8'%x 11 inches in size. <br /> –See reverse side for instructions for completing this application. PE (TION <br /> i. APPLICANT INFORMATION–PLEASE PRINT ALL INFORMATION. Fo VARIANCE ❑YES ❑ NO <br /> Pw ERrTY PROPERTYLOCA <br /> / TION <br /> 6cvt C� tr o> C � f S'W'/4 Nuj'/4 S e1 fT N, R t 71? (or)W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME <br /> C 'P'U V-V is tea' <br /> CI Y,S ATE ZIP CODE PHONE NUMBER VILLAGE: . NEARE T O D,LAKE OR LANDMARK <br /> Sar w /s B 7l/3 <br /> II. 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. a. 19 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. W 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. [21 seepage Bed b. ❑ Seepage Trench c. ❑ Seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. W TER SUPPLY: <br /> (Min tea per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): q�7 <br /> 2 e� 6 S— (D 4�dn l ( ' Feet I)d F rivate ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> Manufacturer's Name Con- Ste il Plastic <br /> INFORMATION <br /> New Existing Gallons Tanks Concrete strutted glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank X 1 Q 6 0 <br /> Lift PumD Tank/Si hon 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): PI Si nature:IN Stam s) MP/MPRSW No.: Business Phone Number: <br /> 0 3 o S <br /> Plumber's ddress(Street,City, tate,Zip Code): Nam Designer: <br /> W air to <br /> VIII. SOIL TEST INFORMATION <br /> Cerrd Soil Test(CST)Name h S CST# 1 <br /> le 4 <br /> CST's ADD ESS(Street,City, tate,Z Code) Phone Number: <br /> W� z t- T S gQ /,r') 0" 2717 <br /> IX. OUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee Groundwater ate Issuing Agent gnature(No Stamps) <br /> �}� Surcharge Fee <br /> pproved ❑ Owner Given Initial C1L <br /> Adverse Determination –lam <br /> X. COMMENTS/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)IF,03/86) DISTRIBUTION: Original to County,One Copy To Bureau of Plumbing,Owner,Plumb <br />