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SANITARY PERMIT APPLICATION DO TY <br /> In accord with ILHR 83.05,Wis. Adm. Code <br /> ST TE SANITARY RMIT# <br /> Lg <br /> —Attach complete plans(to the county copy only)for the system, on paper not less than ST TE PLAN I.D.NUMBER <br /> 8%x 11 inches in size. <br /> -See reverse side for instructions for completing this application. PEI(TION <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. Fo VARIANCE ❑YES ❑ NO <br /> PROPERTY OWNER PROPERTY LOCATION <br /> rr F / C. Sa- N IV Q1.Sjff '/a, S T 3 , N, R-14 a(or W <br /> PROP TY O NER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISI NAME <br /> CITY,ST[qT�/--ff ZIP CODE PHONE NUMBER CITY NEAREST R D�,.L}AKE OR LANDMARK <br /> �.�1'GO S /tee.- l.�J / f l� VILLAGE: -Cr A/ V Al I 4f' <br /> If. TYPE OF BUILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family151 OR ❑ Public(Specify): <br /> Ill. 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 Agreeme t 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. El IGP <br /> In-Fill Tank <br /> V. ABSORPTION SYSTEM INFORMATION: (Check one) <br /> 1. a. N Seepage Bed b. ❑Seepage Trench c. ❑ seepacie Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6JWA ER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED((Square Feet): ? I3 / S- q 0 3 Feet Iate ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in allons Total #OfManufacturer's Name Prefab. Con- Fiber- plastic Exper. <br /> INFORMATION New xistin Gallons Tanks Concrete glass App. <br /> Tanks Tanks structed <br /> Se tic Tank or HoldingTank a ( L4r- t- ❑ <br /> Lift Pum Tank/Siphon Chamber ❑ <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 's ignature: No Stamps) MP/MPRSW No.: Business Phone Number: <br /> rtc c 0S /Jr/ <br /> lumber's ddress(Street,Citf,State,Zip Code): Name of esigner: <br /> w's <br /> VIII. SOIL TEST INFORMATION <br /> Certi d Soil T star(CST)game CST# <br /> Cc ld�d <br /> CST's ADD SS(St eel,City,State,Zip Cod ) Phone Number <br /> e S r _ s Y;P <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee Groundwater ate Issuing Agent Signature(No Stamps) <br /> Approved ❑ Owner Given Initial min urcharge Fee , I_�-� ' <br /> Adverse Determination 'coLx•� r�T1-CJ /lJ\lTi' Lf r .[ // / � <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 />