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��LMR SANITARY PERMIT APPLICATION C TY <br /> In accord with ILHR 83.05,Wis.Adm. Code rn <br /> ST TE SANITARY P1;3ERMIT3U# <br /> I! 3 <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. PE rITION <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES ❑ NO <br /> PROPERTY OWNER PROPERTY LOCATION <br /> iBr u c •e Gr /71 /UC '% JUC'/a, S T N, R S B(or) W <br /> PROPERTY OWNER'S MAILING A RESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME <br /> r 03o g y ,UA nlA <br /> CITY,STATE ZIP CODE PHONE NUMBER LJ CITY NEAREST F CAD,LAKE OR LANDMARK <br /> it r LtY O�C IM TOWN OF: <br /> ❑ VILLAGE: S• W/'SS S I N7 `C. 1,U <br /> 11. TYPE OF 6UILDING 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. ❑ 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. N 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. EYSee a e Bed b. ❑Seepage Trench c. ❑ Seepage Pit <br /> 2. PERCOLATION RATE 3, ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): r� <br /> /S_ 6 q Q 9�• Feet J�Pi ivate ❑Joint ❑ Public <br /> CAPACITY <br /> VI. TANK in allons Total Site <br /> INFORMATION #Of Manufacturer's Name Prefab. Con- Stee Fiber- Plastic Exper. <br /> New xisting Gallons Tanks Concrete strutted glass App. <br /> Tanks Tanks <br /> Septic Tank or Holdin Tank X /qua lar C, ❑ <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.: Bu iness Phone Number <br /> �"r h T a 3 0 i ss. <br /> Plumber's Address(Street,City,State,Zip Code): Na f Designer: <br /> W /O I T r— W r- r <br /> VIII. SOIL TEST INFORMATION <br /> Ce tied oil Tester(CST)Nam CST# <br /> Q er�cf' <br /> CST's ADDRESS(Street,City,State, ip Code) Phone Numb r: <br /> W-e Iz I T (r— w ' .r Y <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved I Sanitary Permit Fee Groundwater ate Issu' gent Si net (No Stamps) <br /> pproved ❑ Owner Given Initial y1� 00 Surcharge Fee (, <br /> Adverse Determination vV �/ �.5' <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 />