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SANITARY PERMIT APPLICATION cD <br /> UILHFI In accord with ILHR 83.05,Wis.Adm. Code <br /> STATE SANITARY ERMIT <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than STATE <br /> PLAN I. MBER <br /> 8%x 11 inches in size. <br /> —See reverse side for instructions for completing this application. <br /> PETITION <br /> i. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑ves ❑ No <br /> PROPERTYOWNER PROPERTY LOCATION <br /> E ''/a,f,F '/a, S Z T, q, N, R el AqO<W) <br /> PRO V WNER'S MAILING ADDRESS LOT NUMBER I BLOCK NUMBER SUBDIVISION NAME <br /> S� <br /> CITY,STATE ZIP CODE PHONE NUMBER CITY NEAREST ROAD,LAKE OR LANDMARK <br /> t S .. 0 ❑ VILLAGE: <br /> jP <br /> 11. TYPE OF 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. ❑ New b. L IIOReplacement 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. FiC ventional 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. PR"Te a e 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): f71� <br /> is ��. Feet rivate [ Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in gallons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New Existing Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank a045 ❑ El ❑ <br /> Lift Pump Tank/Si hon 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 Stam s) ,y1►/MPRSW No.: Business Phone Number: <br /> i <br /> CL'Cs S K 1 .R06 5 -3 <br /> Plumber's Address(Street,City,State,Zip Code): Name of Designer: <br /> VIII. SOIL TEST INFORMATI N <br /> Certified Soil Tester(CST)Name CST# <br /> F Y� <br /> CST's cADrDRESS(Street,City,State,Zip Code) Phone Number: <br /> IX COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Perm it Fee Groundwater ate Issu A ent Signa (No$tamps) <br /> Approved ❑ Owner Given Initial (/ryr�� S rchafrge Fee �Q <br /> Adverse Determination "" "" �7•,or. 6-�9 `-' <br /> X. COMMENTS/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTIONOriginal to County,One Copy To:Bureau of Plumbing,Owner,Plumber <br />