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-�- SANITARY PERMIT APPLICATION co NTY <br /> � aLHR In accord with ILHR 83.05,Wis.Adm. Code <br /> ST TE SANITARY PERMIT# <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'h x 11 inches in size. <br /> -See reverse side for instructions for completing this application. PE ITION <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. FO 3 VARIANCE ❑YES ❑ NO <br /> PROPERTY OWNER PROPERTY LOCATION <br /> RA7 Url S '% S''/s, S ' TZI�J, N, R E (Or;fP <br /> PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME <br /> /7 664 ST. 6 YIA- Ar,l2'M / 614 Ts <br /> CITY,STAT�Es 1t,� ZIP CODE PHONE NUMBER CITY NEAREST FOAD,LAKE OR LANDMARK <br /> �lLll/-FYJ��l] Ji/ J�S�a U w) VILLAGE : -,�-�-- <br /> 11. TYPE OF BUILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family _7H3 OR ❑ Public(Specify): <br /> 111. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) <br /> 1. a. DkNew 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.(Conventional b. ❑ Alternative C. ❑ Experimental <br /> 2. a. ❑System- b. ❑ Holding c.El Pit Privy d. ❑ Vault Privy e. ❑ Mound f. IGP <br /> In-Fill Tank <br /> V. ABSORPTION SYSTEM INFORMATION: (Check one) <br /> 1. a.USeepage 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): PROPOSED(Squar Feet): <br /> es / <br /> -lfJ Feet ❑P ivate ❑Joint El Public <br /> VI. TANK CAPACITYin allons Total #of Prefab. Site Fiber- Exper. <br /> INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Stee glass Plastic App <br /> Tanks Tanks structed <br /> Septic Tank or Holdin Tank /2C%O ( laE�$ � ` <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): PI - i lure: St po MP/MPRSW No.: Business Phone Number. <br /> � �! �j7 — y , 3SZyc <br /> Plumber's Address(Street,City,State,Zip Codej. Name of Designer: <br /> R7 -3 wD 7 > 12 , ( 4- <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name CST# <br /> Rotia� ,7 c- Qn� z 6� <br /> CST's ADDRESS(Street,City,State,Zip Code) Phone Numb r: <br /> U S S 6 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee Groundwater ate Issui A nt Si natu a No Stamps) <br /> Approved ❑ Owner Given Initial Surcharge Fee <br /> r �( <br /> Adverse Determination 3 kj' �s• <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 />