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GILHR SANITARY PERMIT APPLICATION COUNT <br /> In accord with ILHR 83.05,Wis. Adm. Code <br /> STATE SANITARY RMIT# <br /> jj-Aqq <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBER <br /> 8'h x 11 inches in size. <br /> —See reverse side for instructions for completing this application. p ITION <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. F R VARIANCE ❑YES ❑ NO <br /> PROPEF�QWNER r PROPERTY LOCATION <br /> S /Y�Y AJQ o tS d ['/a fje %, S T , N, R /&- 4E (or)W <br /> PROPERTY OWNER'S MAILING ADDRESS LOTNU kgBER BLOCKS fy18ER SUBD�SI N NAME <br /> CITY,`$TATE --'F- ZIPN✓iC'ODE PHONE�NUMBER CCIITYY f� NEARESfTfRROAD,LAKE OR LANDMARK <br /> rJ .S�I�., ❑ VILLAGE: cf W! �I,S, '6fP- L.fL <br /> It. TYPE OF BUILDING OR USE SERVED: j <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. IN New b. ❑ Replacement c. ❑ Replacement of d. ❑ Reconnection of e.El 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 requirement_+ <br /> 4. El The System is shared by more than one owner/building. Attach Common Ownership Agreem Int 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 I. p IGP <br /> In-Fill Tank <br /> V. ABSORPTION SYSTEM INFORMATION: (Check one) <br /> 1. a. M 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): �^ <br /> �6/s— �' y 0 dp iJ Feet ®PI ivate El Joint ❑ Public <br /> VI. TANK CAPACITY <br /> n allons Total #of Prefab. Slte 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 Ot?! ) (.J'C ❑ <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): Plu is Signature: o Stamps) MP/MPRSW No.: B iness Phone Number: <br /> umber's Address(Street,ritq,State,Zip Code): Name of Designer: <br /> VIII. SOIL TEST INFORMATION <br /> Ce Pied Soil Tester(CST)Name CST# <br /> CST's ADDRES (Street,City,State,ZFp Code) Phone Numb r: <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee Groundwater ate Issu g gent Si natu oStamps) <br /> Approved ❑ Owner Given Initial Q�. S charge Q <br /> Adverse Determination a �^11J 0 <br /> X. COMMENTS/REASONS FOR DISAPPROVAL: <br /> I <br /> SBD-6398(formerly Plb-67)in,03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber) <br />