Laserfiche WebLink
SANITARY PERMIT APPLICATION C TYr <br /> 7DILHR In accord with ILHR 83.05,Wis. Adm. Code <br /> .a,:...,e•a.,�,�..v. SATE SANITARY ERMIT# <br /> A <br /> a �5 <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than SI ATE PLAN I.D.NUMBER <br /> 8'h x 11 inches in size. <br /> —See reverse side for instructions for completing this application. PE TITION <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES ❑ NO <br /> PROP TY QWNER JPROPERTY LOCATION <br /> VV U e t—T �1 -t r� J'/aSW %, S rf T �D, N, R y Poo W <br /> PROPE$7VOWNER''M LING ADDRESS UMBER BLOCK NUMBER SUBDIVISI NiNAME <br /> CITY,STATE ZIPCODE PHONE NUMBERITY //v/''r NEARE�j OAD,LAKE OR LANDMARKp2vvt Or� SQ $c1T ILLAGE:OWNOF .� C C �T Ere C+/ <br /> Ilk- <br /> If. TYPE OF BUILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family OR ❑ Public(Specify): <br /> III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) <br /> 1. a. tp 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. Mconventionai 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. 9 seepage Bed b. ❑Seepage Trench c. ❑ Seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 15,SYSTEM ELEVATION 6. W kTER SUPPLY: <br /> (Minutes per inch): REOU/IIRED(Square Feet): PROPOSED(Square Feet): <br /> to l.S 6 (1V /CT 0 Feet t�1 fc� <br /> rivate ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in allons Total #of <br /> Prefab. Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Ste glass Plastic App <br /> Tanks Tanks structed <br /> Septic Tank or Holding Tank 0 Vtl LVIZ— <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' Name(Print): Plumb s Sig ature:IN Stamps) MP/MPRSW No.: B siness Phone Number: <br /> F516o �� �j o�-� <br /> mber's Addre s(Street,City,State,Zip Code): p Na f De igner: <br /> VIII. SOIL TEST INFORMATION <br /> C;r ed So Tester(CST)Name /rte CST# <br /> r`� CS <br /> CST's ADDR SS(Street, dy,State,Zip C e) Phone Num er: <br /> S- ef fe 7is �(a6-�llJ <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee Groundwater ate Iss g gent Sin t e(No Stamps) <br /> pproved ❑ Owner Given Initial Su c-h�arrge Fee D / <br /> Adverse Determination <br /> X. COMMENTS/REASONS FOR DISAPPROVAL: <br /> SBO-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County.One Copy To:Bureau of Plumbing,Owner,Plumber <br />