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SANITARY PERMIT APPLICATION COUNTY <br /> L PJLHR In accord with ILHR 83.05,Wis.Adm. Code SUr <br /> STATE SANITARY P RMIT# <br /> a <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 ❑ NO <br /> PR PERTY OWNER PROPERTY LOCATION <br /> 0 h L n $ W'% IV E'I/4, S lef T ON, R /6,6(a6) <br /> PROPERTY OWNER'S MAILING ADDRESS / LOT NUMBER BLOCK NUMBER SUBDIVISION NAME cL_ <br /> 1 -3 4o ] C_ G �d M Q S�lOa S{lpf <br /> CITY,STA.T-/E- [ ZIP CODE PHONE NUMBER CITY NEAREST ROAD,LAKE OR LANDMARK <br /> rK k e lo.v7 S` , &27❑ VTOWNILLAGE : A) 3 &o e C <br /> IL TYPE OF BUILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family d— OR ❑ Public(Specify): <br /> Ill. 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 /> Lp <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. 9 Seepage 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): PROPOSED(Square Feet): L► A <br /> 3 �•- L o `� Feet /�fS Private ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in allons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- plastic Exper. <br /> INFORMATION New xisting Gallons Tanks Concrete glass App. <br /> Tanks Tanks strutted <br /> Septic Tank or Hold ng Tank 7X0 7 S - UP- <br /> Lift Pum <br /> /-LiftPum Tank/Siphon Chamber I I ❑ ❑ <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): PIe 's Si nature:IN Stamps) MP/MPRSW No.: Business Phone Number: <br /> Ra �e1r�r 0- ) q5--9 is g6 - ch <br /> Plumber' Address(Street,Ci ,State,Zip Code): Name o signer: <br /> W.4 <br /> suer, S� <br /> VIII. SOIL TEST INFORMATION <br /> Certified S 1 Tester(CST)Name CST# <br /> rV6 rtr_ lT Q ,T 7- <br /> CST's ADDRS(Street,City,State,Zip Code) Phone Number: <br /> w Zs7� , ' . s` r s - <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee Groundwater ate Iss ng gent Signatur oStamps) <br /> Approved ❑ Owner Given Initial �U 90 /t7l Surcharge Fee <br /> Adverse Determination JP(y(J l.Jll �•� �- —'-'" <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 />