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SANITARY PERMIT APPLICATION C NTY <br /> DILHR In accord with ILHR 83.05,Wis.Adm. Code STATE ANITARYP MIT# , <br /> — o - 13�c <br /> —Attach complete plans(to the county copy only)for the system, on paper not less than ST TE PLAN L .N BER <br /> 8'h 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. <br /> F VARIANCE ❑YES ❑ NO <br /> PROPERTY OWNER PROPERTY LOCATION <br /> �m r <br /> S,-e rai a n S <br /> S w'/a NE '/e, S T S/0, N, R �o L�(Qr)W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISI N NAME � <br /> Bo / o A), PFS VED CITY i n <br /> / NEAREST OAD,LAKE OR LANDMARK <br /> C`IT'Y,STATE ZIP CODE PHONE NUMBER ❑ VILLAGE: O t �OK d `la W 4 �/ w h <br /> Rf�c it <br /> 11. TYPE OF UILDING OR USE SERVED: 2 <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. 0 New b.❑ Replacement c' ❑ Septic Tank nt of Only d ❑ an Existing System tion of E ❑ Existing System <br /> r of an <br /> System System <br /> 2. ❑ A Sanitary Permit was previously issued. Permit# <br /> 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 Agreem ant to County Copy. <br /> IV. T:a. �g <br /> YSTEM: (Check only one in#1 and only one in#2) <br /> 1onventional b. ❑Alternative c. ❑ Experimental <br /> 2ystem- b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e.❑ Mound f IGP <br /> -Fill Tank <br /> V. ABSORPTION SYSTEM INFORMATION: (Check one) <br /> 1. a. ® See a e Bed b. ❑See a e Trench c. ❑ See a e Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5,SYSTEM ELEVATION 6. ATER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): p. <br /> /6,/-7 <br /> Feet �Private ❑Joint El Public <br /> VI. TANK CAPACITY Prefab. Site Fiber- Exper. <br /> in allons Total #of Manufacturer's Name Concrete Con- S el glass Plastic App <br /> INFORMATION New xisting Gallons Tanks strutted <br /> Tanks Tanks <br /> Se tic Tankor Holdin TankLiftPum 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 pia Business Phone Number: <br /> Plumber's Name(Print): <br /> Plumber's Signature:(No Stamps) MP/MPRSW No.: <br /> P1 03o S is �(c6-v/S <br /> 0 v IG 4% oks Namexesi ner: <br /> Plumber's Add as(Street,City,State,Zip Code): VdIJ <br /> f <br /> VIII. SOIL TEST INFORMATION CST# <br /> Certified Soil Tester(CST)Name 3 <br /> R d `CQ' S Phone N mber. <br /> CST's ADDRESS(Street,City,State,Zip Cod ) 7L p&b y�S <br /> l�T 6 T'r- t,i S. s Q <br /> IX. COUNTY/DEPARTMENT USE ONLY s In Age is t re(No Stamps) <br /> Disapproved Sanitary Permit Fee Suro�utnargetFee ^at <br /> Approvetl ❑ Owner Given initial ("m R-y� CLL`�5 d -16 <br /> Adv erse Determination b(J 60 �J t1 <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,Plun Der <br />