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SANITARY PERMIT APPLICATION (3TY <br /> DILHRIn accord with ILHR 83.05,Wis.Adm. Code s ATESANIARvRMIT# <br /> 4 <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than S ATE PLAN I.D.NUMBER <br /> 8'/x 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 /> PROPERTY OWNER PROPERTY LOCATION <br /> T 4- 5-72?D 5E- '14 AUE '14, S / T,:? , N, R E (olI <br /> PROPERTY OWNER'S MAILING ADDRESSLOT NUMBER BLOCK NUMBER SUBDIVISION NAME <br /> n 6�D/�l%uGZIA) mu SS <br /> CITY,STATE ZIP CODE PH//O NUMBER CITY NEAREST ROAD,LAKE OR LANDMARK <br /> / 4_;f 1 - U2S 1:1 VILLAGE <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. ❑ Replacement of d. ❑ Reconnection of .❑ 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 Agreemeritto 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.n 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 /> Z : o i <br /> J F ��i Feet XPrivate ❑Joint ❑ Public <br /> CA6nks <br /> VI. TANK in gall tal #of Prefab. Site Fiber- Exper. <br /> INFORMATION Newlons Tanks Manufacturer's Name Concrete Con- Ste glass Plastic App <br /> Tankstructed <br /> SepticTank or Holdin Tank �1J . M , ❑ <br /> Lift Pum Tank/Siphon Chamber ❑ ❑ —LL ❑ ❑ <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 nature:(No Stap'll" - MP/MPRSW No.: B siness Phone Number: <br /> �� ti l� C_ Rorer <br /> Plumber's Address(Street,City,Stale,Zip Coca): Name of Designer: <br /> Qt 3 fax COO � G Gc)i s <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name CST# .[{>,5 <br /> C— U l ?I r <br /> CST's ADDRESS(Street,City,State,Zip Code) Phone Number <br /> 12 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved I Sanitary Permit Fee Groundwater, ate Issuing Agents ature(No Stamps) <br /> A roved Syscharge Fee <br /> pp Owner Given Initial �„/� 0-11 <br /> Adverse Determination ViV U lJ �Lf U O !O <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,Plumbe <br />