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SANITARY PERMIT APPLICATION cO Y <br /> (�I DILHR In accord with ILHR 83.05,Wis.Adm. Code <br /> STATE SANITARY PERMIT# <br /> aG - 00 <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBER <br /> 8%x 11 inches in size. <br /> —See reverse side for instructions for completing this application. PETITION <br /> 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES ❑ NO <br /> PROPERTY OWNER PROPERTY LOCATION <br /> o/IAJ S -3& T4f0, N, R 1r E (oro <br /> PROPERTY OW ER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME <br /> /02 4a5 . sTfX�L G7iu637rn asrr. �� Llri <br /> ZIP CODE PHONE NUMBER LJ CITY NEAREST ROAD,LAKE OR LANDMARK <br /> aSpfX N S1• /97A/• -+�O'7 na To❑ VILLAGE : NOtelh 54A-7) 69/4eF <br /> If. TYPE OF BUILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family 3 OR ❑ Public(Specify): <br /> III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4, if applicable) <br /> 1. a. ❑ New b.KReplacement 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. yseepage 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 perint ): REQUIRED(Square Feet): PROPOSED(Square Feet): ell <br /> rD� ZA0 / t ,rFeet V�Private ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Co,_ Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or HoldingTank ❑ ❑ ❑ ❑ <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 tur S[ p MP/MPRSW No.: Business Phone Number: <br /> Plumber's Address(Street,City,State,Zip Code): Name of Designer: <br /> kT -9 /3eeZ - <br /> VIII. SOIL TEST INFORMATION <br /> CertifigPTester(CST)Name CST# <br /> CST's ADDRESS(Street,City,State,Zip Coi Phone Number <br /> de : <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sa itary Permit Fee Groundwater ate Is in Agent Sign a(No Stamps) <br /> Approved ❑ Owner Given Initial //p��r--/// S rcharge//F��e�ee <br /> Adverse Determination Cqj° <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 />