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(� ^ SANITARY PERMIT APPLICATION CCPD Y <br /> U �IL.HR In accord with ILHR 83.05,Wis.Adm.Code <br /> STATESANITARY ERMIT# <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than ST TE PLAN .D. UMBER` <br /> 8'F x 11 inches in size. <br /> —See reverse side for instructions for completing this application. PETITION <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. F R VARIANCE ❑YES ❑ NO <br /> PROPERTY OWNER � PROPERTY LOCATION <br /> i' Qhs �eal /(/� ''/a S_W '/a, S T �0, N, R @(or W <br /> PR BLOC NUMBER SUNNISI N NAME <br /> CITY,STATE ZIP CODE PHONE NUMBERn CITY (.f / NEAREST OA LAKE OR L(PDk4ARK <br /> ,t I R 12 LF-n,j� VILLAGETOWN : O �I// '�QRd UI /l Z�r <br /> II. TYPE OF UILDING OR USE SERVED: ^^ Y <br /> Number of Bedrooms if 1 or 2 Family OR ❑ Public(Specify): <br /> III. PURPOSE OF APPLICATION: (Check only one in#1. Check 1112,3 or 4,if applicable) <br /> 1. a. K 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 Agreeme nt 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. W Seepage Bed b. ❑ Seepage Trench C. ❑ Seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. W TER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): �I <br /> Z 0 'Y -3 �� Feet XP Nate ❑Joint ❑ Public <br /> VI. TANK CAPACITY in allons Total #of Prefab. Site Fiber- Exper. <br /> INFORMATION New Existing Gallons Tanks Manufacturer's Name Concrete Con- Ste I glass Plastic App <br /> Tanks Tanks structed <br /> Se tic Tank or Holdina TankV El <br /> Lift Pump Tank/Siphon Chamber ❑ F1 El ❑ ❑ ❑ <br /> VII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plans <br /> Plumber' Name(Print): PI 's Signature: No Stamps) \ MP/MPRSW No.: Bu iness Phone Number: <br /> r� .4lv r tc k #? fl <br /> Plumber' Ad ss(Street,City,State,Zip Code): Name of Design r: <br /> iT/4r w ' r s P <br /> VIII. SOIL TEST INFORMATION <br /> Certified S iI Tester(C T)Name CST# <br /> CST's AD S( City,State,Zio Code) Phone Numb r: <br /> P s <br /> IX. COUNTY/DEPARTMENT USE ONLY 1-1 <br /> ❑ DisapDrovedSa,,,nLLLitrary Permit Fee Groundwater ate Iss nq ent Si nature Stamps) <br /> Approved F-1 Owner Given Initial `N ,�q-v S�ch��F� <br /> Adverse Determination <br /> j�(J lJ l�� �1101 cJs.J �� <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 />