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SANITARY PERMIT APPLICATION Co TY <br /> DILHR In accord with ILHR 83.05,Wis. Adm. Code ST TESANIITARY ERMIT#-1111 <br /> a 1316q <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I D.INUMBFR <br /> 8%x 11 inches in size. <br /> —See reverse side for instructions for completing this application. PETITION <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES ❑ NO <br /> PROPERTVOWNER PROPERTY LOCATION <br /> nen r L o h SE '/e /., S ,:.3 T O, N, R / 7 IF(or) W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME <br /> OS' Pn r C: 0k1 rT Se- Al M- Ill A <br /> ZIPCODE II �l G0 Al NEARES'TfROG A9,CTV, 0 AE OR QL�CITY / AZ <br /> PHONENUMBERRK <br /> VILLAGE: <br /> fhSV[` // M . / <br /> 11. TYPE OF BUILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family OR ❑ Public(Specify): <br /> 111. 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. ®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. 9F Seepage Bed b. ElSeepacie 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): q r <br /> I/ 4p/3 ' G 9,p < �S Feet Private El joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in allons Total of Prefab. Fiber- Exper. <br /> INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank 6� L�.J �' <br /> I Li I Li <br /> Lift Pump Tank/Siphon Chamber L ❑ ❑ <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): L Plu is Signature:(No Stamps) MP/MPRSW NO.: Business Phone Number: <br /> �Qd-er`IC � t'Fd II ,nS r7-aLFRa�JL Oa QX_ <br /> Plumber' Address(Street,City,State,Zip Code): Name esignec <br /> w e t s r- s" C <br /> VIII. SOIL TEST INFORMATION <br /> Certif Soil ester(CST)Name CST# ` <br /> Q �trr,C & « r �j <br /> CST's ST's ADDRESS Street,City,State,Zip Code) Phone Number: <br /> Wc _.e S- ( 7!5" 8G 6- YDS <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee I Groundwater ate Issu' ent Sign IN rings) <br /> Approved ❑ Owner Given Initial �) S charge,FMee� <br /> Adverse Determination A-^ <br /> w <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 />