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SANITARY PERMIT APPLICATION CO NTY <br /> (�I DILHRBU_ VETT <br /> In accord with ILHR 83.05,Wis.Adm.Code <br /> p e ST TE SANITARY PERMIT# <br /> 1a8 i3a)3 <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBER <br /> 834 x 11 inches in size. <br /> —See reverse side for instructions for completing this application. PE (TION <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FO VARIANCE ❑YES FIND <br /> PROPERTY OWNER PROPERTY LOCATION <br /> -) I,E A. NELSON SE, '/4 NE Ya, S 3 T 39 , N, R 24 JO) W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISI NAME <br /> STA'.I 30UT: NA I NA NA <br /> CITY,STATE ZIP CODEPHONE NUMBER CITY : NEAREST ROAD,LAKE OR LANDMARK <br /> SPOOPdi '3 I Lp801 o TOWNvILLAGE: :2USK B?N IT LAKE <br /> IL TYPE OF BUILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family 2 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 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 t to County Copy. <br /> IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2) <br /> 1. a. M 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. ❑ Seeoacle Bed b. ❑Seepage Trench C. ® Seepage Pit <br /> 2. PERCOLATION RATE 13. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. W TER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): <br /> NA NA NA NA Feet 12P rivate ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in allons Total #Of <br /> Manufacturer's Name Prefab. Con- Ste Fiber- plastic Exper. <br /> INFORMATION New xistin Gallons Tanks Concrete structed i glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank U ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ <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): Plumber's Signature.(No Stamps MP/MPRSW No.: Bu iness Phone Number: <br /> AdLYIv J. Hi7;LT," •/x/J• 3360 15 635-7595 <br /> Plumber's Address(Street,City,State,Zip Code): Name of Designer: <br /> 1 SPOONS +?I 54.801 <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name CST# <br /> sAI,TE 3331 <br /> CST's ADDRESS(Street,City,State,Zip Code) Phone Number: <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved ISanitary Permit Fee Groundwter ate Issu' g em Si na (No Stamps) <br /> Approved F-1Owner Given Initial S rchargeaFee y ''7 ,�,,�/ <br /> Adverse Determination P,S• /r`a3� ,v <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 />