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(�, u SANITARY PERMIT APPLICATION COU TY <br /> V UILHR In accord with ILHR 83.05,Wis. Adm. Code <br /> p e STATE SANITARVP RMIT# <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.N ER <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 /> 4 X f t/a / '/4, S T,?9, N, R ! or W <br /> PROPERTY OWNER'S MAILING AD_fjESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME <br /> X14 AM <br /> CITY,STATE ZIP CODE PHONE NUMBER L.1 CITY NEAREST ROAD,LAKE OR LANDMARK <br /> �tw/'c (i C7 U E3 VILLAGE, <br /> If. TYPE OF BUILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family .Z 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. X Replacement of d. ❑ Reconnection of e.❑ Repair of an <br /> System System Septic Tank Only an Existing System Existing System <br /> 2. ElA Sanitary Permit was previously issued. Permit# 0R j o — Date Issued�Q Ex <br /> ,5 <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. `Li' See a e Bed b. ❑Seepage Trench c. ❑ Seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 14. ABSORPTION AREA 15.SYSTEM ELEVATION 6. WATER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): <br /> Feet ❑Private El Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in allons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- PlasticLExper.INFORMATION New xisting Gallons Tanks Concrete glassTanks TanksstruttedSe tic Tank or Holdin Tank O ei / CCFFG TT ILILift Pum Tank/Si hon 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): Plumber's Signature:(Normps) W/MPRSW No.: Business Phone Number: <br /> Ec;4 i r` o Jb�o/ ?/S �3 7'r/o <br /> Plumber's Address(Street,City,State,Zip Code): Name of Designer: <br /> T <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name CST# �� <br /> CST's ADDRESS(Street,City,State,Zip Code) Phone Number: <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee Groundwater ate Issuing gent Signalure(No Stamps) <br /> roved Surcharge Fee f^�r�� <br /> pp ❑ Owner Given Initial (�(},) /`� �t-�c Q'O XX <br /> Adverse Determination I-Vim/ V1 OGT CJ�V 'J V . . 'vv`q <br /> X. COMMENTS/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb£7)(R.03/86) DISTRIBUTION: Original to County,one Copy To:Bureau of Plumbing,Owner,Plumber <br />