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�1LHR SANITARY PERMIT APPLICATIONr__1DSu rn <br /> ,�• _ In accord with ILHR 83.05,Wis. Adm. Code ST NTE SANITARY PERMIT# <br /> S 13636 <br /> -Attach complete plans(to the county copy only)for the system, on paper not less than Sr TE PLAN I.D.NUMBER <br /> 8Yz x 11 inches in size. <br /> -See reverse side for instructions for completing this application. PE rITION <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES ❑ NO <br /> PROPERTY OWNER EPRIOPERTYION <br /> C � � � ro , S q T YQ , N, R (o E (or)W <br /> PR PERTY OWNER'S MAILING ADDRESS BLOCK NU BER SUBDIVISI N NAME <br /> e 3YYM itCITY,ST}A-TE ZIP CODE PHONE NUMBER NEARES OA LAKE OR LANDMARK <br /> 1 Vr ,1^ 7 S- Q k l K d .� <br /> 11. TYPE OF BUILDING OR USE SERVED: �/8J- 3y 8S- <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. ® 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. Dd 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. 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 /> (Minutes per inch): REQUIRED(Square Feet): PRO/P'OSED(Square Feet): Q <br /> Feet JlF P ivate ❑Joint ❑ Public <br /> CAPACITY VI. TANK C #of Prefab. Site Fiber- Exper. <br /> in gallons Total Manufacturer's Name Con- Ste Plastic <br /> INFORMATION New xisting Gallons Tanks Concrete glass App. <br /> Tanks Tanks y� G structed <br /> Septic Tank or Hold ng Tank / Sd f ❑ ❑ <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): PI 's Signature:( o Stamp ) MP/MPRSW No.: Bu iness Phone Number: <br /> 'CM M.J D 3 O 0 If <br /> Plumber' Adwess(Street, ,State,Zip Code): Name of Designer: <br /> lupi? a /Y r' 4t s. J— <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester, <br /> Name CST# 7 <br /> 0 e- S / <br /> CT's ADDy ESS(Street,City,State,Zip Code) Phone Number: <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee Groundwater Date Iss Agent Si nat a( tamps) <br /> Approved <br /> F-1ownerGiven Initial Surcharge Fee yA <br /> Adverse Determination wo'/v�'`�'�� �S• r+ <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 />