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SANITARY PERMIT APPLICATIONlr <br /> �' DILHR In accord with ILHR 83.05,Wis.Adm. Code S7 TEs NITAR PERMIT# <br /> laSol <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ST TE PLAN I.D.NUMBER <br /> 8'%x 11 inches in size. <br /> -See reverse side for instructions for completing this application. PE rITION <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. F R VARIANCE F-1 YES ❑ NO <br /> PROPE337Y WNER PROPERTY LOCATION <br /> c� L b vJ W S M(_�k 'a '/4 MVV '/4, S X(8 T1j11A/, N, R A (or) W <br /> PROPERTY OWNER'S MAILING ADDRESS�,.yC LOTN MBER BLOCK SUBDIVISION TIME <br /> CITY,STATE ZIP CODE// PHONE NUMBER CITY O VILLAGE /dT NEAREST OAD,LAKE OR LANDMARK <br /> s <br /> d C sa y : <br /> II. 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. 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 Agreem ntto 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 f. IGP <br /> In-Fill Tank <br /> V. ABSORPTION SYSTEM INFORMATION: (Check one) <br /> 1. a. N 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 /> , C_ o- S r�0 Z �_ Feet ®P Nate ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Ste I glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank x Sd C- ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ I L ❑ ❑ ❑ <br /> VII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plans <br /> Plu er's Name(Print): PI is Signature: o Stamps) MP/MPRSW No.: B iness Phone Number: <br /> Plumber's Ad s(Street,Cit ,State,Zip Code): V Na Designer: <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name CST# <br /> CST's ADDRESS(Street,City,Slate,Zip Code) Phone Numb r: <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee I Groundwater Pate Iles Agent Sin nature(No Stamps) <br /> Xpproved ❑ Owner Given Initial //y^) (�) S rcharge/F�eee� I <br /> Adverse Determination 10 - as, /I)_D <br /> D-w W01 <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 />