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SANITARY PERMIT APPLICATION GG�/l��TY' <br /> 7 0ILHR In accord with ILHR 83.05,Wis.Adm.Code STATE SANITAR PERM IT# <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I. .NUMBER <br /> 8'/z 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 ❑ves ❑ No <br /> PROP RTY OWNER �LOT�NUMRTY LOCATION <br /> �� '/a /a, S T N, R — E (o <br /> PROPERTY O ER'S MAILING ADDRESS BER BLOCK NUMBER SUBDIVISION NAME <br /> Zlitel/,fl '3 i f N/ q— N IU 4- <br /> CITY,STATE ZIP CODE PHONE NUMBER NEAREST ROAD,LAKE OR LANDMARK <br /> t LAGE7A9, L �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*ew b. Replacement c. El 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.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP <br /> In-Fill Tank <br /> V. ABSORPTION SYSTEM INFORMATION: (Check one) <br /> 1. a.%Seepage Bed b. ❑Seepage Trench c. ❑ Seepage Pit <br /> 2. PER OL TION RATE 3. ABSORPTION AREA4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): <br /> -[ Fe KPrivate ❑Joint ❑ Public <br /> VI. TANK CAPACITY #of Prefab. Site Fiber- Exper. <br /> 1n 11 ns Total Manufacturer's Name Con- Steel Plastic <br /> INFORMATION New xisting Gallons Tanks Concrete glass App. <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank (� r 1:1Lift Pump Tank/Siphon Chamber ❑ 1 ❑ I ❑ I ❑ ❑ <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): Ill gnature:( StanMP/MPRSW No.: Business Phone Number: <br /> Qn p� U tQ{ 07� lE <br /> Plumber's Address(Street,City,State,Zip ode): //� �j� Name of Designer: <br /> T 7 l7/fGZ.- 1 / <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tesler(CST)Name . CST# �� <br /> b�Z�-1 E O IT- �v <br /> CST's ADDRESS(Street,City,State,Zip Code) / Phone Number: <br /> / Col— -xV —3S09, <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee Groundwater Date Issui ent Signa re oSlamps) <br /> pproved F-1OwnerGiven Initial /,y���) Surcharge Fee <br /> Adverse Determination ��"" --✓ g5' <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 />