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rz(�. <br /> SANITARY PERMIT APPLICATION CO T�ILNR In accord with ILHR 83.05,Wis. Adm. CodeST TE SANITARY P IRMIT# <br /> f <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than ST TE PLAN 1.9.N MBER <br /> 8'h x 11 inches in size- <br /> -See reverse side for instructions for completing this application. PE ITION <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. Fo I VARIANCE ❑YES ❑ NO <br /> PROPERTY OWNER PROPERTY LOCATION <br /> o 44 r- S -5 a r I SL '/a SW ''/a,S 7 T yO N, R 6 I*(or W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER I SUBDIVIS11 N NAME <br /> o / 3 S �/ r 0 Q 1 <br /> CITY.STATE ZIP CODE PHONE NUMBER T7 CITY NEAREST ROAD,LAKE OR LANDMARK <br /> O VILLAGE <br /> hL <br /> II. TYPE OF/BUILDING OR USE SER ED: <br /> Number of Bedrooms if 1 or 2 Family OR ❑ Public(Specify): <br /> III. PURPOSE OF APPLICATION: (Check only one in#1. Check 42,31 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 ownerlbuilding. Attach Common Ownership Agreemeit to County Copy. <br /> IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2) <br /> 1. a. 5 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. Ud 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): PROPOSED(Square Feet): q <br /> d 3 / Feet PP ivate ❑Joint C Public <br /> VI. TANK CAPACITY Site <br /> in allons Total #of Pre tab. Fiber- Exper <br /> INFORMATION New xistingGallonsi Tanks Manuidciurer'SName oncrete Con- St I glass Plastic App. <br /> Tanks Tanks structed <br /> Septic Tank or Holdin Tank _74ru I C_ ❑ <br /> Lift Pump Tank/Siphon Chamber 11 ❑ <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.: B iness Phone Number: <br /> o ;c k a ins 0-:�0 7-5 -Y!r <br /> Plumber's Address(Street,City.State,Zip Code): Na Desi ner: <br /> � � sgLf <br /> Vill. SOIL TEST INFORMATION <br /> Certified it Tester(CST)Name CST# <br /> 0 r« 0 A- h f <br /> CST's ADDRESS(Street,City,State,ZipCode) Phone Num r <br /> Y - ll <br /> IX. OUNTYIDEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee Groundwater ate Issu- g ge nt Si e(No Stamps) <br /> Approved ❑ owner Given Initial SurchargeFee <br /> Adverse Determination ' as'W <br /> SD <br /> X. COMMENTSIREASONS FOR DISAPPROVAL: <br /> S8D-6398(formerly Plb-67)(R 03/86) D"STRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner.Plumber <br />