Laserfiche WebLink
SANITARY PERMIT APPLICATION GN <br /> 7UILHR In accord with ILHR 83.05,Wis.Adm.Code <br /> ��•'�"��• aATE$RNjTARY MIT# <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than TATE IPPL11A!_N I.D.NUMBER <br /> 8'%x 11 inches in size. <br /> -See reverse side for instructions for completing this application. ETITION <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES ❑ No <br /> PROP RTY OWNER PROPERTY LOCATION <br /> akE <br /> S A, Sc ''1 �E'/a, S T N, R,0 E (orrC <br /> PROPERTY OWNER'S MAILING ADDRESS LOTNUMBERBLOCK NUMBER SUBDIVISION NAME <br /> �x 36P AL&6eliz7QW, 55/x` -3 <br /> CITY,STATE ZIP CODE PHONENUMBER CIN NEAREST ROAD,LAKE OR LANDMARK <br /> O VILLAGE : <br /> 11. TYPE OF BUILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family �i - 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. ❑ Replacement c. ❑ Replacement of d.❑ Reconnection of .❑ 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 Agreem nt to County Copy. <br /> IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2) <br /> 1. a. Xconventional b. ❑Alternative C. ❑ Experimental <br /> 2. a. ❑System- b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound I. ❑ IGP <br /> In-Fill Tank <br /> V. ABSORPTION SYSTEM INFORMATION: (Check one) <br /> 1. a.'101Seepage Bed b. ❑Seepage Trench c. ❑ Seepage Pit <br /> 2. PER OLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5. Y TEM ELEVATION 6. W TER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED S uarre�Feet): <br /> Feet PqFrivate ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in gallons Total #of Manufacturer's Name Prefab. Con- Ste Fiber- plastic Exper. <br /> INFORMATION New xistin Gallons Tanks oncrete glass App. <br /> Tanks Tanks structed <br /> Septic Tank or Holding Tank 54272 <br /> Lift Pump Tank/Siphon Chamber I <br /> / rPp L) I Li I Ll <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): PJymber•s•Siga9tu e: St m MP/MPRSW No.: Bu iness Phone Number: <br /> pAR1N� e- (\ 3d7� e� ?tlq S <br /> Plumber's Address(Street,City,State,Zip Code: , Name of Designer: <br /> t AO <br /> VIII. SOIL TEST INFORM TION <br /> Certij[ed Soil Tester(CST)Name , C <br /> ST- ��2�r�-t- <br /> CS 's ADDRESS(Street,City,State,Zip Code) r: <br /> IX I OUNTYIDEPARTMENT USE ONLY <br /> ❑ Disapproved I Sanitary Permit Fee Groundwater ate Is su' g gent Si at r No Stamps) <br /> Approved ❑ Owner Given Initial S=harge r2re <br /> Adverse Determination • ,-4t�Tl CC-�D vlJ <br /> X. COMMENTS/REASONS FOR DISAPPROVAL: <br /> SSD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber <br />