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SANITARY PERMIT APPLICATION co Tv <br /> � D1LHR In accord with ILHR 83.05,Wis. Adm. Code r� <br /> STATE SANITARY RMIT# <br /> 114aO,Q 19o3 <br /> rr <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 /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES [-] NO <br /> PROPERTY OWNER t PROPERTY LOCATION <br /> 7 aA9 ♦c ik AwskC $u1 '/41W114, S ,2r T.38 ,C9R /,? E (Dr& <br /> PROPERTY OWNER'S MAILING ADDRESS LOT NUMBERBLOCK NUMBER SUBDIVISION NAME <br /> CITY,STATE O ZIP CODE PHONE NUMBER CITY A NEAREST ROAD,LAKE/ a <br /> OR LANDMARK <br /> /V O. .S'T I-f�U//r//tl �' i(1� �j/.] 7��-3� O VILLAGE : GJpt r1/(�PJr L/r GJ oGf./ /a .'Q• <br /> II. TYPE OF BUILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family 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. ®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. X Conventional b. ❑ Alternative C. ❑ Experimental <br /> 2. a. ❑System- b. ❑ Holding c.11 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. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 15.SYSTEM ELEVATION 6. WATER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): <br /> S /7 (j 3o 7 3 Feet ®Private [-]Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in allons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. <br /> INFORMATION New xistingGallons Tanks Concrete glass App. <br /> Tanks Tanks strutted <br /> Septic Tank or Holdin Ta O GOl7 r�I G ❑ ❑ <br /> Lift Pum Tank/Siphon amber �� [ r ❑ © ❑ ❑ ❑ <br /> VII. RESPONSIERL.ITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Plumber's Name(Print): Plumber's Signator Nc Stam ) MP/MPRSW No.: Business Phone Number: <br /> G4gde /)ay5;Ao/r-, <br /> Plumber's Address(Street,City,State,Zip Code): Name of Designer: <br /> X _ 4)eY-&C 9 <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name CST#� r Q 3 <br /> W d t <br /> CST's ADDRESS(Street,City,S)ate,Zip Code) Phone Number: <br /> a <br /> IX. COUNTY/DEPA TMENT USE ONLY <br /> ❑ Disapproved San tary Permit Fee Groundwater ate Issu A ent Signature amps) <br /> Approved <br /> El Given Initial `v��, Surcharge Fee <br /> Adverse Determination "`-"M �;Se <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 />