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I — SANITARY PERMIT APPLICATION Gut-ne-4 <br /> DILHR In accord with ILHR 83.05,Wis.Adm. Code <br /> STATE SANITARY PRN T#/ I <br /> 119 `y'1 <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D. 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 ❑YES ❑ No <br /> P RTY WNER ,,��'' �j PROPERTY LOCA TION <br /> �yt{� {�LGf� S6 '% 1/4, S S T�O, N, R t'lbr W <br /> P PERTY OWNER'SJIGQILLIING A-DDDRESS LOT NUy1BER BLOCK NUMBER IS DTVI N N`n Q'� <br /> CITY,STA'TTE 'bVt� ZIPCODE PHONE NUMBER CITY/_ NEAIRA7ESSITROA AK RLANDMARK <br /> . .n LeL(J Yr' JJ /� .7) S .u( VILLAGE : <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. 19 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. 11 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. ®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. XSeepage Bed b. ❑Seepage Trench c. ❑ Seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: <br /> Z/ (Minutes p r inch): REQt�U/IRED(Square Feet): PROP��O//SED(Square Feet): j 1 <br /> -' — / W® 7�� f i 71S Feet W Private ❑Joint ❑ Public <br /> VI. TANK CAPACITY <br /> n allons Total #of Prefab. Ste Fiber- Exper. <br /> INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks11 strutted <br /> 'Septic-Tank rHoldin Tank < <es ❑ ❑ ❑ ❑ <br /> Tank/Si hon Chamber ❑ 71 ❑ ❑ F1 <br /> VII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility fors nstallation of the private sewage system shown on the attached plans. <br /> Plumber's ame(Prin : Plu er's Si nature:( o S ps) MP/MPRSW No.: Business Phone Number: <br /> m Q �S P f r W S--2P / n 6�f <br /> Plumbe dress(Street,City,State, ode):• Name of Designer: <br /> �. 7i � SY�t is <br /> VIII. SOIL TEST INFORMATION <br /> Car ified Soil Tester(CST)Name CST# <br /> S -2/ <br /> CST' ADDRESS(Street,City.State,Zip Code) Phone Number: <br /> U)Q <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee Groundwater ate Issuing Agent nature(No Stamps) <br /> xSurcharge Fee <br /> Approved ❑ Owner Given Initial `-i,� A_�y_<X/ �J <br /> Adverse Determination �"�` �`-' �.7 U v o <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 />