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SANITARY PERMIT APPLICATION G NTY <br /> � DILHR In accord with ILHR 83.05,Wis. Adm. Code <br /> STATE SANITARY PERMIT# <br /> —Attach complete plans (to the county copy only)for the system,on paper not less than ST NTE PLAN I.D. UMBER <br /> 8% x 11 inches in size. <br /> —See reverse side for instructions for completing this application. P ITION <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. F R VARIANCE ❑YES ❑ NO <br /> PROPERTY OWNER PROPERTY LOC/ATION ,/ <br /> 50vl O�JQrJrJCS 5Z1-%/t/W'%, S 7 T S'0, N, R �1 E (or W <br /> PROPERTY O ER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME <br /> 6933 Gest 0/i've it/ 8 — 16v oai5 <br /> CITY,ST TE ZIP CODE <br /> PHONE NUMBER CITY : /�, _/ NE EST ROAD,LAKE OR LANDMARK <br /> G'rove,InAI ggSB S/ SP7 VILLIN AGE C C2/66/77 P.// N1 /&I/e, <br /> II. TYPE OF BUILDING OR USE SERVED: �,,/ <br /> Number of Bedrooms if 1 or 2 Family ACLed,l CO17'1S OR ❑ Public(Specify): <br /> Ill. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4, if applicable) <br /> 1. a. 0 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.XConventional 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. 9Seepaae Bed b. ❑Seepage Trench c. ❑ Seepage Pit <br /> 2. PERCOLATION RATE 13. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. W NTER SUPPLY: <br /> (Minutes per inch): REQUIRED�q uare Feet): PROPOSED(Square Feet): �� _ <br /> 05 `e11 /'/Y/ Feet XFrivate ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> I lions Total #of Prefab. Fiber- LA <br /> INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Ste I glass Plastic <br /> Tanks Tanks strutted <br /> Septic Tank or HoldingTank 7� 50 ��C ❑ ❑ <br /> Lift Pum Tank/Si hon 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.: B amass Phone Number: <br /> 2Ct�e .eu� ic�m <br /> Plumber's Address(Street,City,State,Zip Code): Name of Designer: <br /> a� 1-w <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name CST# <br /> aG*_ 61—XVI" P3 <br /> CST's ADDRESS(Street,City,State,Zip Code) Phone Number <br /> c5a177e 7/sA&do- XIP <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved S itary Permit Fee Groundwater ate ui Agent S re(No Stamps) <br /> A roved pn� Sµµµrcharge Fee / i <br /> pp ❑ Owner Given Initial L-�V `� (C 0 <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,Plumbe <br />