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4 D1LHR SANITARY PERMIT APPLICATION Co Y <br /> In accord with ILHR 83.05,Wis. Adm. Code <br /> s ST TESANITARYP RMIT# <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than S TE PLA 1.15.N I BER <br /> 8'%x 11 inches in size. <br /> —See reverse side for instructions for completing this application. PE ITION <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FO I VARIANCE ❑YES ❑ NO <br /> PROPERT OWNER PROPERTY LOCATION <br /> /111 . Fr I Y L S W'11a N %, S .3d T fd, N, R 6 [(or) W <br /> PROPERTY OWNER'S MAILING ADDRESS LOTNOMBER BLOCK NUMBER SUBDIVISIC NNAME <br /> S` 3.1 *� S VA Jt� n e t <br /> CITY,STATE ZIP CODE PHONE NUMBER CITY NEAREST AD,LAKE OR LANDMARK <br /> O rc-r a".{, LtLt, All -A'S'0 tr 0 VILLAGE : <br /> II. TYPE OF BUILDING OR USE SERVED: I ` <br /> Number of Bedrooms if 1 or 2 FamilyOR ❑ Public(Specify): <br /> III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) <br /> 1. a. 0 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 it to County Copy. <br /> IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2) <br /> 1. a. �9 Conventional b. ❑Alternative C. ❑ Experimental <br /> 2. a. ❑System- b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. 11 IGP <br /> In-Fill Tank <br /> V. ABSORPTION SYSTEM INFORMATION: (Check one) <br /> 1. a. M seepage Bed b. ❑Seepage Trench c. ❑See a e Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WA rER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROP�O/SED(Square Feet): /+7 <br /> 3 T 1 V` `[ �— 7`' Feet Pr vate ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in allons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. <br /> INFORMATION New mating Gallons Tanks Concrete glass App. <br /> El <br /> Tanks Tanks structed <br /> Septic Tank or HoldingTank 7J. 0 I t�) L ❑ <br /> Lift Pum Tank/Si hon Chamber ❑ ❑ <br /> VII. RESPONSIBILITY STATEMENT <br /> 1,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Plumber's <br /> Name(Print): Plum 's Signature,(No Stamps) MP/MPRSW No.: Bus ness Phone Number <br /> Plumber's Address(Street,city,State,Zip Code): Name of Designer <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(C T)Name FP222umbei <br /> CTARSeet,City,State,Z p Code) <br /> IX COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee Groundwater ate Issu ant Sig at (No Stamps) <br /> Approved ❑ Owner Given Initial Surcharge Fee <br /> Adverse Determination OWO <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 />