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SANITARY PERMIT APPLICATION Go' TY <br /> 'Z� DILHR In accord with ILHR 83.05,Wis. Adm. Code / <br /> v STATE SANITARY ERMIT <br /> o la <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLANID NUMBER <br /> 8'%x 11 inches in size. <br /> —See reverse side for instructions for completing this application. PES ITION <br /> 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. F R VARIANCE ❑YES ❑ NO <br /> JPROPERTY OWNER PROPERTY LOCATION <br /> / .vE '/4PLI %, S A) TN, R 6 E (0 W <br /> PROPERTY OWNER'S MAILING ADDRESS S (OS- LOT NUMBER BLOCK NUMBER SUBDIVISI N NAME <br /> 5 F I.E' ��� 0Z- ,v ,v,} v u> <br /> CITY,STATE ZIP CODE PHONE NUMBER LJ CITY NEAREST ROAD,LAKE OR LANDMARK <br /> ❑ VILLAGE : DA / <br /> If. TYPE OF BUILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family a OR ❑ Public(Specify): <br /> III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) <br /> 1. a. �( ew b. ❑ Replacement c. El Replacement of d. ❑ Reconnection of ei❑ 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. ICi.Conventional b. ❑Alternative C. ❑ Experimental <br /> 2. a. ❑\System- b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. I❑ IGP <br /> In-Fill Tank <br /> V. ABSORPTION SYSTEM INFORMATION: (Check one) <br /> 1. a. ee a e Bed b. ❑ Seepage Trench c. ❑ seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 15.SYSTEM ELEVATION 6. W TER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): <br /> �fs�1 it II <br /> `�/ Feet grivale ❑ <br /> Joint nt ❑ Public <br /> VI. TANK CAPACITY Site <br /> no allons Total Ifof Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. <br /> INFORMATION New fisting Gallons Tafnks Concrete structed glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank eLKC <br /> Litt Pum Tank/Siphon Chamber ❑ El El <br /> ❑ ❑ <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): P er ' nature:(No Sta MP/MPRSW No.: Bus=Phoner: <br /> It— ZeV <br /> Plumber's Address(Street,City,State,Zip Code): Name of Designer: <br /> R 3 S o r- (17 Uix <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name CST# <br /> CST's ADDRESS(Street,City,State,Zip Code) Phone Num er: <br /> X T 8 � / &J/, D )/s - 3 --V <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee Groundwater ate Issui Agent S.gnatu re(No Stamps) <br /> F-1Owner Given Initial � ,p/� Sur harge F/e¢e <br /> pproved �p/fB/ <br /> Adverse Determination "^t7o•VV <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 />