Laserfiche WebLink
- MMMININ SANITARY PERMIT APPLICATION c TY <br /> In accord with ILHR 83.05,Wis.Adm. Code <br /> -- <br /> STATE SANITAR PERMIT <br /> q- <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBER <br /> 8'f2 x 11 inches in size. <br /> --See reverse side for instructions for completing this application. PETITION <br /> 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE F-1 <br /> YES ❑ NO <br /> PROPERTY OWNEq PROPERTY LOCATION <br /> y.-� - S �e e'/a ,(/ '/a, S /7 T 'y0, N, R 17 IP(or) W <br /> PROPERTY OWNER'S MAILING ADDRESS LOTNUMBER BLOCK NUMBER SUBDIVISION <br /> N� AlNAME <br /> A <br /> CITY,STAJE ZIP CODE PHONE NUMBER CITY NEAREST ROAD,LAKE OR/LANDMnAR <br /> DPNVO/ W O VTOWN ILLAGE: h 6) Aj <br /> II. TYPE OF bUILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family AL_ 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 Agreement to County Copy. <br /> IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2) <br /> 1. a. 5d 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. Seepage Bed b. ❑Seepage Trench C. ❑ Seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 15.SYSTEM ELEVATION 6. WATER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROP/O E(Square Feet): Q'7 I� <br /> 91 q1Q T / / 7/ Feet �I rivate ❑Joint 1:1 Public <br /> VI. TANK CAPACITY #of Prefab. Site LE <br /> Exper. <br /> in allons Total Manufacturer's Name Con- Steel Plastic <br /> INFORMATION New xistin Gallons Tanks Concrete App. <br /> Tanks Tanks structed <br /> Septic Tank or HoldingTank 7SU 7 S^v W G ❑ ❑ <br /> Lift Pum 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.: Business Phone Number: <br /> a o /% r 4At&Ly 6,3 d S lis 966-%IS-1 <br /> Plumber's A dre, (Street,City,State,Zip Code): Na of Designer: <br /> ukn 's go Q <br /> VIII. SOIL TEST INFORMATION <br /> Cer d Soil/Tester(CST) ame CST# <br /> gCf rl-t C, ! t �(`1 S T <br /> CST's ADDRE S(Street,City,State,Zip Code) Phone Number <br /> t <br /> P r - ye- <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved I Sanitary Permit Fee Groundwater ate 'ss g gent Signatu oStamps) <br /> S charge Fee <br /> pproved ❑ Owner Given Initial ea5 <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 />