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SANITARY PERMIT APPLICATION GO TY <br /> F:(� DILHR In accord with ILHR 83.05,Wis. Adm. Code i <br /> aobt— <br /> ST TE l!SANITARY PERMITS -- <br /> s <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than S7 TE PLAN I.D. UMBER <br /> 8'h x 11 inches in size. <br /> —See reverse side for instructions for completing this application. PE ITION <br /> 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FO VARIANCE ❑YES ❑ NO <br /> PROPERTY OWNER PROPERTY LOCATION Gov't• Lc73 <br /> o r f n IUB Ya /J lv Ya, S a y T yv, N, R s L+ (Dr W <br /> PROP TY OWNER'S MAILI ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME <br /> � � ft !r o <br /> CITY,STATE ZIP CODE PHONE NUMBER 7 ❑ VILLAGE : �PrCr NI:U ST DAD,L K OR LANDMARK <br /> SS d'f �'/)—13 <br /> II. 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 Agreemt nt 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. 191 Seepage Bed b. ❑Seepage Trench c. ❑ See a e Pit <br /> 2. PERCOLATION RATE 13. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. W TER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): <br /> L 1.. 0 L � (0 1 I Feet rivate ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in allons Total #ofPrefab. Fiber- Exper. <br /> INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank S'O ) tj C-- ❑ ❑ ❑ <br /> Litt Pum Tank/Si hon Chamber ❑ LE ❑ ❑ ❑ <br /> VII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plant <br /> Plumber's Name(Print): Pll/uumbber's[Q,/{$Gignature: No Stamps) MP/MPRSW No.: B siness Phone Number. <br /> 1` Q V. l P I G 17 r 1 4 O ` /•� <br /> Plumber's Address(Street, ity, tate,Zip Code): Name of Designer: <br /> u,�e b s-7;-r- <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name CST# \ <br /> ��eV'�c � Ihs j <br /> CST's ADDRESS(Street,City,State,Zip Code) Phone Num er: <br /> l v kAA' �^ lS FW- lS <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee Groundwater ate Issuing Agent gnature(No Stamps) <br /> Approved ❑ Owner eSyychasrgeFyeelr�e <br /> AdverseDetermination Ta ��l .•r /'/r <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 />