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SANITARY PERMIT APPLICATION D <br /> (� al HR�p In accord with ILHR 83.05,WIS.Adm. Code 07;rneff­ <br /> S1 ATE SANITARY P MIT# <br /> 1337 <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than S1 ATE PLAN 1.0.NUMBER <br /> 8%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 ❑VES ❑ NO <br /> PROPERTY OWNER LPRO�PERTY LOCATION <br /> {� r -e -e ''/s #F %, S 3 TY0, N, R (o F (or)W <br /> PROPERTY OWNER'S MAILING ADDRESS U�ER BLO,K'U1.�1BER SUBDIVISI)N NAME <br /> aZIP CODE PHONENUMBER I ,V ,AC / NEAREEVS/T CAD,LAKE OR LANDMARK <br /> w Ot � Loti d CJ 4 <br /> 11. TYPE OF BUILDING 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. b. <br /> 1471 <br /> Replacement c. ❑ Replacement of d.❑ Reconnection of e ❑ Repair of an <br /> Btem 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. EIIGP <br /> In-Fill Tank <br /> V. ABSORPTION SYSTEM INFORMATION: (Check one) <br /> 1. a. A Seepage Bed b. ❑See a e Trench c. ❑ Seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 15.SYSTEM ELEVATION 6. W TER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): C, p f <br /> 7 a o v- e2 a l� ( 0• Feet Ifid rivate ❑Joint ❑ Public <br /> CAPACITY <br /> VI. TANK Site <br /> in allons Total #of Prefab. LFiber- Exper. <br /> INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Ste I PlasticAppTanks Tanks strutted <br /> Se tic Tank or Holdin Tank lar ` ❑ ❑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 plan <br /> Plumber's Name(Print): PIu er's Signature:(No Stamps) MP/MPRSW No.: B siness Phone Number: <br /> Fe 49..r t f2 63 Q s- >Is' $6 ^W S-7 <br /> lumber's Add rgss(Street,City,State,Zip Code): Name of Designer: <br /> VIII. SOIL TEST INFORMATION <br /> C <br /> ie d oil Tester( T)Nam CST# h <br /> LC 1 Q �(I'L T / <br /> CST's ADD' <br /> SS( City,State,Zip Code) ,p Phone Num r: <br /> .T- <br /> 14. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sayn�itary Permit Fee SGroundwater ate Iss ng gent Si na No S[amps) <br /> Approved F-1 Owner Given Initial <-U 11 /0 cc ctt 1r �Fee <br /> Adverse Determination �-I ll vim- Ip of vu CT U <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 />