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SANITARY PERMIT APPLICATION co TY <br /> fl �1�HR In accord with ILHR 83.05,Wis.Adm.Code <br /> SIATESANITAKYYtHMII N <br /> a <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D. UMBER <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. I FOR VARIANCE ❑YES ❑ NO <br /> PRORERTYOWNER PROPERTY LOCATION )/ <br /> il • r rc o ri JW 1/a /VJ'/a, S T N, R OSE(or) W <br /> PROPERTY OWNER'S MAILIINNG ADDRRE`SS LOT UM ER BLOCK tIUMBER SUBDIVISION NAME <br /> CITY,STA E '01((rr ZIP CODE PHONE NUMBER CITY A114NE/ARREE/STTC ROAD,LAKE OR LANDMARK <br /> o. ❑ VILLAGE: I'T410it /i Vv n Orr. <br /> 4 <br /> I(IV <br /> Il. 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. 115conventional 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. Seepage Bed b. ❑Seepage Trench c. ❑ Seepage Pit <br /> 2. PACT LATION RATE 3. ABSORPTION AREA 14. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): A <br /> Q 6 3 Q `t A { Feet I Private ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Expp. <br /> INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks (ATC-4110structed <br /> Se tic Tank or Holdinq Tank 7SM I ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ F-1F-1 <br /> VII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plans. <br /> PI tier's Name(Print): Plu er's Signature: No Stamps) [Name <br /> P/MPRSW No.: Business Phone Number: <br /> Plumber's dress(Street, ,State,Zip Code): of l n r: <br /> GJ` � <br /> Vlll. SOIL TEST INFORMATION <br /> Cepd SJ,Tester(CST Name CST# <br /> I <br /> CST's ADOR SS(Street,City,State,Zip ode) Phone Number: <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee Groundwater ate Issuing A ant Signature(No Stamps) <br /> Approved ❑ Owner Given Initial /_�` Sch� Fee <br /> 6 �,) <br /> Adverse Determination �) <br /> X. COMMENTS/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)F.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber <br />