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SANITARY PERMIT APPLICATIONCVC, <br /> NTY <br /> ( 31LHR In accord with ILHR 83.05,Wis.Adm.Code V('r r4 F'FT <br /> S AT ANITAR P MIT# <br /> SIAT <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBER <br /> 8%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 /> P RTY OWN f / i PROPERTY LOCATION <br /> Kllt� e Y4, S 17 T V1, N, R r W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUB ISION NAME <br /> :;z � `l 04 11-1 1 r I La e ( L77C1 <br /> CITY,STATE ZIP CODE PHONE NUrM�-B�ER CITY NEARES OA LAK R LANDMARK <br /> Wocd ✓r t"r'VI .r 2 .^ , I-5 VILLAGE :SwtS <br /> 11. TYPE OF B ILDING OR USE SERVED: Pl A t 4 4 y f R OOC{- <br /> Number of Bedrooms if 1 or 2 Family OR ❑ Public(Specify): <br /> Ill. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4, if applicable) <br /> 1. a. N 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. 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. See a e Bed b. ❑See a e Trench c. ❑ See a e it <br /> 2. PER OLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SSr-SYSTEM ELEVATION 6. WATER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): C� <br /> �A t -3 l 3r - Feet 6; <br /> Private [01 joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App- <br /> T1 <br /> pp <br /> Tanks Tanks strutted <br /> Se tic Tanko Holdin Tank1I ,l "es or N(r ❑ ❑ ❑ <br /> -177fu—mpTank/Siphon Chamber I I I I I ❑ ❑ ❑ ❑ ❑ ❑ <br /> VII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility f-r installation of the private sewage system shown on the attached plans. <br /> Plumber's Name <br /> d�(//Print): PI mber's$ignatu :(Ne'Stamps) MP/MPRSW No.: Business Phone Number: <br /> PiVs Address(Street,City,Slate, ,p Co e): Name of Designer: <br /> I <br /> VIII. SOIL TEST INFORMATION <br /> Cert fie Soil Tester(C N me CST# <br /> 14-L. Vrl <br /> CST's ADDRESS(Street,City,Staty Zip Cope) Phone Number: <br /> v �0 Io S 'tom ' uo <br /> ly, COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee Groundwater Date Issu gent Signat oStamps) <br /> Approved ❑ Owner Given Initial (v�,(� (�(�1 <br /> charge Fee /t,�.-.,�� �I�,/ �n�'�7 <br /> Adverse Determination `lv "`-' Com" -'"' " " <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 />