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SANITARY PERMIT APPLICATION COUNTY <br /> LDILHR In accord with ILHR 83.05,Wis. Adm. Code rr' <br /> STATE SANITARY PE IT <br /> 1124 <br /> —Attach complete plans(to the county copy only)for the system, on paper not less than STATE PLAN I.D.NUMBER <br /> 8% 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 /> PROPERT WNER PROPERTY LOCATION <br /> 7191 e A !� w/a , S X246 T 4/(), N, R f S-E (G W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME <br /> All Sb 4t)&` S n.A <br /> CITY,STATE J ZIPCODE PHONENUMBER CITY NEAREST ROAD AK OR LANDMARK <br /> T9%7P�► l2�U,q d ToMDF <br /> VILLAGE T.re- SOiv �i11!Fel <br /> 11. TYPE OF BUILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family i OR ❑ Public(Specify): <br /> Ill. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4, if applicable) <br /> 1. a. Ll New b. �2S,J Replacement c. ❑ Replacement of d. ❑ Reconnection of e.❑ Repair of an <br /> System ystem 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.L1 Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP <br /> In-Fill Tank <br /> V. ABSORPTION SYSTEM INFORMATION: (Check one) <br /> 1. a.X Seepage Bed I I b. ❑-Seepage Trench c. ❑ See a e Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AR 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: <br /> (Minutes per inch): REQUIRED(Squa PROPOSED(Square F <br /> 0 ( q-2,CJ n <br /> Feet rivate ❑Joint ❑ Public <br /> VI. TANK CAPACITY I Site <br /> INFORMATION in gallons total..... #of Prefab. Fiber- Exper. <br /> New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks stn ucted <br /> Septic Tank or Holding Tank 750 17501 ❑ ❑ ❑ ❑ <br /> Lift Pump 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): Plumb re:(No mp MP/MPRSW No.: Business Phone Number: <br /> � <br /> Plumber's Address(Street,City,State,Zip ode): I Name of Designer: <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(C me CST# <br /> n g� c/6� <br /> CST's ADDRESS(Street,City,State,Zip Code) Phone Number: <br /> RT 41 a <br /> S <br /> Or9r �I Vt'3 v (7i <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee Groundwater Date Iss n Agent Signat No Stamps) <br /> Approved ❑ Owner Given Initial /X^r�1 (,e�(��) S rrchharge Fee <br /> Adverse Determination Vv ' �`--' '�`S- �I <br /> X. COMMENTS/REASONS FOR DISAPPROVAL: (57 <br /> SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber <br />