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SANITARY PERMIT APPLICATION Cou�TY/ ' <br /> afHLHR In accord with ILHR 83.05,Wis. Adm. Code i / <br /> STATE SAN ITA V2l#a l <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. B <br /> —See reverse side for instructions for completing this application. PETITION <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES ❑ NO <br /> PROPERTYOWNER / LPROPERTY LOCATION <br /> o t l A .S T 'XSZO '/4, S a2I T 3.r, N, R I8 e(or) W <br /> PROPERTY OWNER'S MAILING ADDRESS NUMBER BLOCK NUMBER SUBDIVISION NAME <br /> 87„77 /a� JVANC .frq•'I <br /> CITY,STATE ZIPCODE� PHONE NUMBER ITY ))) NEAREST ROA LANDK <br /> .CA� SS^07pA i�aZ 7J0 I.��. IOWNOFLLAGE: Ki9,, <br /> �. <br /> It. TYPE OF BUILDING OR USE SERVED: Or <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. ❑ New b.24%1.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.X Alternative C. ❑ Experimental <br /> 2. a. ❑System- b. R1 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. ❑ Seepage Bed b. ❑Seepage Trench c. ❑ seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 15.SYSTEM ELEVATION 6. WATER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): Q�_ <br /> /✓ `� Feet ®Private ❑Joint ❑ Public <br /> CAPACITY <br /> VI. TANK Site <br /> in allons Total #ot Prefab. Fiber- Exper. <br /> INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks structed <br /> Septic Tank or Holdin Tank ro J I ❑ ❑ <br /> Lift Pump 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): Plumber's Signature:(No Stamps) MP/MPRSW No.: JBBua,,n,ess Phone Number: <br /> s Y�2 a2a�s <br /> Plumber's Address(Street,City,State,Zip Code): Naarryw ofDesig er: �� L <br /> 11 `� <br /> VIII. SOIL 7EST INFORMATION <br /> Certified Soil Tester(CST)Name CST# } <br /> / /1 w-¢ r- <br /> CST's ADDRESS(S)feet,City,State,Zip Code) Phone Number: <br /> 4-/ -)—arclit <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee Groundwater ate Issuing A nt Signature(No Stamps) <br /> Approved ❑ Owner Given Initial w/ T` �Npy�� S harge Fee <br /> Adverse Determination 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 />