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fi DILHR SANITARY PERMIT APPLICATION CCU Y <br /> In accord with ILHR 83.05,Wis. Adm. Code r <br /> ST NTE SANITARYP M??dITn# <br /> � /01Y <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. PETITION <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. F VARIANCE ❑YES ❑ NO <br /> PROPERTY OWNER D PROPERTY LOC9TION '/ <br /> Four _5-Z 050n,5 /� � 2NUMBE130 <br /> .5E'/4 SSWY4, S 7 T YO, N, R E (orrq <br /> PROPERTY OWNER'S MAILING ADDRESSLOT NUMBER BLOCK NUMBER SUBDIVISION NAME <br /> &,y /3p / — 11-v G�,5 <br /> CITY,ST9T/E . / ZIP CODE PHONECITY rNEARE/ST OAD,LqKE OR LANDMARK <br /> / CK/ m/l/ SS037 �p�oVILLAGE : /)n ed/ <br /> It. TYPE OF BUILDING OR USE SERVED: {� (/�� <br /> Number of Bedrooms if 1 or 2 Family o? OR ❑ Public(Specify): <br /> III. 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 Agreem nt to County Copy. <br /> IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2) <br /> 1. a. K'2 Conventional b. ❑ Alternative c. ❑ Experimental <br /> 2. a. ❑System- b. ❑ Holding c.1:1 Pit Privy d. ❑ Vault Privy e. ❑ Mound f. IGP <br /> In-Fill Tank <br /> V. ABSORPTION SYSTEM INFORMATION: (Check one) <br /> 1. a. 9 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(Sq are Feet) <br /> Y : <br /> /o 1 �7/� <br /> 7 Feet gFrivate ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in ga ons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Ste glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank 70 1 — MC ❑ ❑ ❑ <br /> I El <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ I ❑ I ❑ <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 StampBs) MP/MPRSW No.: iness Phone Number: <br /> k/ode eu{�ho/i» Gr/�.e�44 33Co/ 7/S 0&&- 7aP6, <br /> Plumber's Address(street,City,State,Zip Code): Name of Designer: <br /> (oma nut/ ktl(f ri kI&fzh im <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name CST# <br /> ode &{mho/rrt 3 P13 <br /> CST's ADDRESS(Street,City,State,Zip Code) Phone Num r: <br /> SCt/NC� 7/,1- <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved I Sanitary Permit Flee Groundwater a"7 <br /> t Is ing ent Sin (No Stamps) <br /> ❑ Owner Given Initial <br /> Approved �—NO•LTJ Surcharge CS, e� <br /> Adverse Determination <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 />