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SANITARY PERMIT APPLICATION COUNTY <br /> � D1LHR In accord with ILHR 83.05,Wis.Adm.Code (✓ h E 4 <br /> _ ATE SANITARY P MIT# <br /> _ <br /> �rl <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN Lb.N BER <br /> 8'h x 11 inches in size. � `—S , <br /> —See reverse side for instructions for completing this application. PETITION <br /> 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES NO <br /> PR PERTY OWNER PROPERTY LOCATION G <br /> n � ) 0 S )' '/4�W'/4, S Z N, R/ <br /> W <br /> PBOPERTV OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME <br /> J�ll' <br /> CITY,STA, {���EI- I ZIP CODE PHONE NUM EZR CITY NEARES OA LAKE OR L D ARK <br /> � r� IS!lVf� �./; �> 0 VILLAGE : <br /> II. TYPE OF BU DING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family -� OR ❑ Public(Specify): <br /> Ill. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) <br /> 1. a. X 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 Agreement to County Copy. <br /> IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2) <br /> 1. a. ❑Conventional b. W Alternative c. ❑ Experimental <br /> 2. a. ❑System- b.)Q Holding c.El Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP <br /> In-Fill Tank <br /> V. ABSORPTION SYSTEM INFORMATION: (Check one) <br /> 1. a. ❑ See a e Bed b. ❑See a e Trench c. ❑ seepage Pit <br /> 2. PERCOLATION RATE 13. ABSORPTION AREA 14. ABSORPTION AREA 15.SYSTEM ELEVATION 6. WATER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): <br /> feet ❑Private ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in gallons Total #of Mfacturer's Name Prefab. Con- Steel Fiber- plastic Exper. <br /> INFORMATION New xisting Gallons Tanks Concrete structed glass App. <br /> anu <br /> Tanks Tanks <br /> Se tic Tanko oldin Taao <br /> m El El Q <br /> Lift Pum Tank i hon Chamber <br /> 11 <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 PIu ber's S' ature:( S ps) MP/MPRSW No.: Business Phone Number: <br /> lumb is Address(Street,City,Sta Zip Code): t ,..,,..,De igner <br /> L L/ S �< <br /> VIII. SOIL TEST INF RMATION <br /> Car ifi Soil Tester(CST.Name CST# <br /> tC�Z. ' _4( � •>Z <br /> CS 's ADDREESS-(Street,City,Stat P Cgde) Phone Number: <br /> 19, COUNTY/DEPARTMENT USE ONLY <br /> F-1 Disapproved S nary Permit Fee Groundwater at Issuing gent Signature(No Stamps) <br /> rchar a ee <br /> Approved ❑ OwnereDetarmin l� <br /> Adverse Determination 11111111 <br /> X. COMMENTS/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.03186) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber <br />