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(� SANITARY PERMIT APPLICATION COU <br /> ! D1LHR In accord with ILHR 83.05, Wis.Adm.Code <br /> �•�^'��• —^�- STI TE SANITARYP MIT# <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NU BER-a� <br /> 8Y 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 /> PROP�WNER EN <br /> TY LOCATION /'^ <br /> JOe T 40, N, R ]b E ( W <br /> PROPERT OWNER'S MAILING ADDRESS BER BLOCKNUMBER SUBDIVISION NAME <br /> CIT�_STATE ZIP CODE PHONE NUMBER CITY AGENEAREST ROADLAKE OR LAN MARK <br /> tre - aF0a <br /> 11. 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. k New b. ❑ Replacement c. ❑ Replacement of d. ❑ Reconnection of e.❑ Repair of an <br /> System System Septic Tank O r1, f an Existing System cE7xisting System <br /> 2. A Sanitary Permit was previously issued. Permit# 14 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. 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. Seepacte 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): REOUIR�(Square Feet): PROPOSED(Square Feet): <br /> 3 a Feet Private ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in allons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- plastic Exper. <br /> INFORMATION New xisting Gallons Tanks Concrete glass App. <br /> Tanks I Tanks structed <br /> Septic Tank or Holding Tankd O ( - C-P— f j ElF-1 19 F-1 ❑ <br /> Lift Pump Tank/Siphon Chamber Ll I ❑ ❑ ❑ ❑ <br /> VII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Plum er's Name(Print): umber's Sign :(No Stamps) 1 MP/MPRSW No.: Business Phone Number: <br /> Plumber's Address(Street ty,State,Zip Co!d Name of Designer: <br /> VIII. SOIL TESTI FORMATION <br /> C <br /> led S it Tester(CST)Nam EPh,14; <br /> inf:CT's DDRESS(Stree,City,State, ip Code) be <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee Groundwater ate Issuing Agent Signature(No Stamps) <br /> Approved ❑ Owner Given Initial Surcharge Fee <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 />