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SANITARY PERMIT APPLICATION <br /> C� cou TY <br /> U 61LHR In accord with ILHR 83.05,Wis.Adm. Code <br /> STATESANITARY PERMIT# <br /> 91 as S <br /> —Attach complete plans (to the county copy only)for the system, on paper not less than STATE PLAN I.D. UMBER <br /> 8'h 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 ❑YES ❑ NO <br /> PROPS TY OW--�NER ,p PROPERTY LOCATION <br /> ES /teeS�'% .sCvp 1/a, S . T , , N, R �t6 (or) W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCKN BER SUBDIVISION NAME <br /> S Ll¢ r n N E !U A/`14 <br /> CITY,STATE ZIP CODE PHONE NUMBER CITY : NEAREST ROAD,LAKE OR LANDMARK <br /> 0 VILLAGE : SgLTOWNOF <br /> u,�� t <br /> If. 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. XReplacementof 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. tpl 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. X Seepage Bed b. ❑Seepage Trench c. ❑ Seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): <br /> Feet ❑Private ❑Joint ❑ Public <br /> VI. TANK CAPACITYin ons Total #of Prefab. Site Fiber- Exper. <br /> INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks structed <br /> Septic Tank or Holding Tank BOOL C. ®,� ❑ ❑ ❑ ❑ <br /> Lift 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 /> PI ber's/IName(Print): Plu 's Si nature:(No amps MP/MPRSW No.: Business Phone Number: <br /> odtwc c 0 05 /S' <br /> Plumber's Aiddress(Street,Citilf,State,Zip Code): Nam Designer: <br /> w s- <br /> VIII. SOIL TESTINFORMATION <br /> Car"d Soil (CST ST NaTe CST# <br /> CST's ADDRESS(Street,City,State,Zip Code) Phone Number: <br /> 8 i <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> F—] DisapprovedSanitary Permit Fee Groundwater ate Issuing gent Signature(No Stamps) <br /> X �Approved ❑ Owner Given Initial (/ry^� //y���� S rcharge Fee / r/�l <br /> Adverse Determination � 0-M �'� ' — /—s� <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 />