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DiLHR SANITARY PERMIT APPLICATION G Y <br /> In accord with ILHR 83.05,Wis. Adm. Code <br /> ST TE SANITARY PERMIT <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ST kTE PLAN I.D. MBE. <br /> 8'%x 11 inches in size. <br /> -See reverse side for instructions for completing this application. PE rITION <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. FC I VARIANCE ❑YES ❑ NO <br /> PROPERTY OWNER PROPERTY LOCATION <br /> S e d rt l es tiW '/4 S '/4, S T //ON, R 0 (or)W <br /> PROPERTY O�EMAILING ADDRESS LOTNUMBER BLNXUMBER sUB�gVISI ASM ^ JYr <br /> CIThhYSTATE ZIP CODE PHONE NUMBER CITY+3 /.. NEAREST 0 ,LA/K�E OR LANDMARK <br /> ❑ VILLAGE: AyflCtJ <br /> If. TYPE F BUILDING OR USE SERVED: <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. M 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 Agreem nt 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. ABSORP ON SYSTEM INFORMATION: (Check one) <br /> 1. a. <br /> 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): p <br /> 3 1 0 a / -P Feet NPrivate ❑Joint ❑ Public <br /> CAPACITY <br /> VI. TANK Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Ste I glass Plastic App <br /> Tanks Tanks strutted <br /> Se tic Tank orHoldin Tank ,r0 1 ( C Lj Ll <br /> Lift Pump Tank/Siphon Chamber 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): PlunnqA4 Signature:(No Stamps) MP/MPRSW No.: B iness Phonnee Number: rI <br /> 6 y�QrIC CA.f ^ Q oT- 7/,slS7- 46` <br /> Plumber's P(,dd�res�s(Street,City,Slate,Zip Code): Name of Designer: <br /> Vlll. SOIL TEST INFORMATION <br /> Certif Soil ester(C T)Name CST# <br /> c, nr rs cn i S620 <br /> CST's ADD/ijESS(Street,City,State,Zip Code) p Phone Num r: <br /> L.I.T Y1-S l{ W^ S d Q /1- <br /> IX. OUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee Groundwater ELI <br /> Is sui nt Si nature o amps) <br /> )(Approved urcharge Fee❑ Owner Given Initial (,�.qy� 5• <br /> Adverse Determination �) vll <br /> X. COMMENTS/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.03/86) D'STRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber <br />