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(�, ^ SANITARYPERMIT APPLICATION DOD" Y <br /> Ll U'LHR In accord with ILHR 83.05,Wis. Adm. Code - <br /> STATE SAN ITA Ry PERM ��� <br /> 79 <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBER <br /> 8'h 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 [ANO <br /> PROPERTY OWNER PROPERTY LOCATION <br /> / N l�e e /a S'cw '/a, S 13 T p , N, R/ R(or) W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME <br /> / ac's' / 3/Sr ST /Vn 9T///.. omf A4/A/N 9 ^l /0 '� /'IfcAe'vz/e `2-e Ae k <br /> CITY,STATE w� ZIP CODE PHONE NUMBER CITY : NEAREST ROAD,LAKE OR LANDMARK <br /> 1T//w I?TtL �I S Jia S� F-1 10WILaRO VILLAGE : $Co%� AfC/fe rV2/-e KX'e. <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. d 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. XSee a e Bed b. ❑ Seepage Trench c. ❑ Seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOS/ED(Square Feet): <br /> L L <br /> r. <br /> 3 4//o 7 /p 0/317 7 Feet ®Private ❑Joint ❑ Public <br /> V1. TANK CAPACITY Site <br /> I n allons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. <br /> INFORMATION New xistin Gallons Tanks Concrete glass App. <br /> Tanks Tanks strutted <br /> Se tic Tank or Holding Tank '— 'Jb0 / r✓zp Sev 6.,c,, ❑ <br /> Lift Pum Tank/Siphon Chamber ❑ El FH <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:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> (�� _P140 ov Q `I' e leo G3s'a�/87 <br /> Plumbers Address(Street,City,State,Zip Code): Name of Designer: <br /> 5l/3 J H S/ S _-�o 0 A IF4U/S �/Yo 1 <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name CST# <br /> Y� 5 Ne1/n 3331 <br /> CST's ADDRE S(Street,City,State,Zip Code) Phone Number: <br /> 'RO 'Bo )( 71 7/0 & 35-- 75- 9,:i — <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee Groundwater Date Issuing Agent Signature(No Stamps) <br /> Approved ❑ Owner Given Initialmay/ 00 Surcharge Fee 44 <br /> Adverse Determination `v' � D /(/'?S- ,�/ 7 <br /> X. COMMENTS/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)F.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber <br />