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SANITARY PERMIT APPLICATION Cou v <br /> te <br /> 7 fILHR In accord with ILHR 83.05,Wis. Adm. Code r <br /> STATE SANITARYRMIT# <br /> 4� <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUNBER <br /> 8'h x 11 inches in size. <br /> —See reverse side for instructions for completing this application. PETITION <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES ❑ NO <br /> PROPERTY OWNER PROPERTY LOCATION <br /> /�� ��� � Ito 1/4 kL 4, S 7 T C N. R E (or) <br /> PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME r <br /> lac c'!Q !3t1� ���F_ �AAIE 3 ASP�hIP� A A 6 <br /> CITY,STATE of ZIP CODE PHONE NUMBER 11 CITY : NEAREST ROAD,LAKE OR LANDMARK <br /> l-IYJ ,L/A,tJ /al�� 15-524/7 ) 1173-3f ❑ VILLAGE : 69& er <br /> TOWN OF <br /> II. TYPE OF BUILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family OR ❑ Public(Specify): <br /> 111. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4, if applicable) <br /> 1. a. V�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. LXJ Conventional b. ❑ Alternative c. El 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. tK Seepage Bed b. ❑Seepage Trench C. ❑ See a e Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 14. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): I PROPOSED(Square Feet): <br /> / 1 Feet Private El Joint El Public <br /> VI. TANK CAPA ITY Site <br /> in allons Total #of Manufacturer's Name Pretab. Con- Steel Fiber- plastic Exper. <br /> INFORMATION New xisting Gallons Tanks Concrete glass App. <br /> Tanks Tanks strutted <br /> Septic Tank or Holdin Tank a 7Sf� T 117. A--e ❑ ❑ <br /> Lift Pum Tank/Si hon Chamber Hi EXT ❑ ❑ <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): Plumb re:(No Stam MP/MPRSW No.: Business Phone Number <br /> -7 7 �Ai <br /> Plumber's Address(Street,City,State,Zip Code): Name of Designer: <br /> 4F'T 3 6F �(' ` DAAll" !b 3 <br /> VIII. SOIL TEST INFORMATION <br /> Certified SoilTester(CST)Name CST# <br /> � CzZCa' 7 Y4Z 11k? 33 <br /> CST's ADDRESS(Street,City,State,Zip Code) Phone Number: <br /> 6- 6, X 7 , ( 71r ) <br /> IX. COUNTY/DEPARTM Eli USE ONLY <br /> ❑ Disapproved S nitary Permit Fee Groundwater ate Issuing gent Sign lure(No Stamps) <br /> pproved ❑ Owner Given Initial I' S rcghaCrgegFeeee 1((j(('� s <br /> Adverse Determination " - �`✓rv� �� -` /LW7 <br /> X. COMMENTS/REASONS FOR DISAPPROVAL: 7 <br /> SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber <br />