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SANITARY PERMIT APPLICATION COU <br /> JJ�TY �}�— <br /> DILHR In accord with ILHR 83.05,Wis. Adm. Code rurne""' <br /> STATE ANITARY I RMIT#� <br /> –Attach complete plans(to the county copy only)for the system, on paper not less than STATE LAN I.D. BEJ/R <br /> 8Yz x 11 inches in size. <br /> –See reverse side for instructions for completing this application. PETITION <br /> 1. APPLICANT INFORMATION–PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES ❑ NO <br /> PROPERTY OWNER ]PROPERTY LOCATION <br /> -72z; wc/-) ,c ''/a5W-/'/s, S �07 T 3gN, R / E (orPROPERTYOW R'S MAILING AD RESS T NUMBER BLOCK NUMBER SUBDIVISION NAME <br /> CITY,ST,�A,,//TE , / ZIP C 9n7DE PH.7ONE NUMBERCITY NEAREST ROAD,LAKE OR LANDMARK <br /> 'rrt'_dent/C' �N.I X37 /�J 'l- VILLAGE : /�S // zo� <br /> II. TYPE OF BUILDING OR USE SERVED: L <br /> Number of Bedrooms if 1 or 2 Family a 011aZn.5 OR ❑ Public(Specify): <br /> III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4, if applicable) <br /> 1. a. 0 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. XConventional b. ❑ Alternative C. ❑ Experimental <br /> 2. a. ❑System- b. ❑ Holding c.L1 Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP <br /> In-Fill Tank <br /> V. ABSORPTION SYSTEM INFORMATION: (Check one) <br /> 1. a. X1 See a e Bed b. ❑Seepage Trench c. ❑ seepage Pit <br /> 2. PERCOLATION RATE 13. ABSORPTION AREA 4. ABSORPTION AREA 15.SYSTEM ELEVATION 6. WATER SUPPLY: <br /> (Minute/s per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): /,, lam( <br /> w^ Y/0 97•w Feet J4�Private ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in allons Total #of 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 HoldingTank .� '—' 7� G ❑ ❑ ❑ <br /> Lift Pum 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' Signature:(No Stamps) MP/MPRSW No.: Business Phone Number. <br /> Plumber's Address(Street,City,State,Zip Code): Name of Designer: <br /> l0 /W/ %ve�5. 100. Ao .cleh�fe� �tfl s/P .t�Qde Psi /m <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tesler(CST)Name CST# <br /> .cf de &1G1201&) 35 3 <br /> CST's ADDRESS(Street,City,State,Zip Code) Phone Number: <br /> zrm� /-5- P610-7a�Co <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved San tary Permit Fee Groundwater ate Issui nt Signature(No ps) <br /> Approved ❑ Owner Given Initial (lC,f�� S r harge((Feee <br /> Adverse Determination ""' /0 <br /> X. COMMENTS/REASONS FOR DISAPPROVAL: <br /> SBD 398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber <br />