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SANITARY PERMIT APPLICATION D TY <br /> 1�1 0JLHR In accord with ILHR 83.05,Wis.Adm.Code STAT SANITARY P MIT# <br /> ( <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than ST TE PLAN I.D.NUMBER <br /> 8%x 11 inches in size. <br /> —See reverse side for instructions for completing this application. P ITION <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. F(R VARIANCE ❑YES ❑ NO <br /> PROPERTYOWNER PROPERTY LOCATION <br /> n em ;7%tve' C Some SE % A)vrt�<, s2 T n , N, R fl(cr) W <br /> PRO ERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCKBER SUBDIVISI N ME <br /> 0 Be / dS <br /> VA �4Al';' <br /> CITY, 7A E ZIP CODE PHONE NUMBER CITY NEAREST OAD,L E OR LANDMARK <br /> �s�s VILLAGE 4 G C <br /> wtPbS�er- Lv'1 9 <br /> It. TYPE OF BUILDING OR USE SERVED: Ips <br /> Number of Bedrooms if 1 or 2 Family N OR LCI Public(Specify): Yff O*c— <br /> III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) <br /> 1. a. 0 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 Agreem nt to County Copy. <br /> IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2) <br /> 1. a. ❑Conventional b.9 Alternative c. ❑ Experimental <br /> 2. a. ❑System- b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e.1�4 Mound f. ❑ IGP <br /> In-Fill Tank <br /> V. ABSORPTION SYSTEM INFORMATION: (Check one) <br /> 1. a. XSee a e Bed b. ❑See a e Trench c. ❑ See a e Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.7SYSTEM ELEVATION 6. ATER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): <br /> 3 7�, 3 � , Feet ® rivate ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION Manufacturer's Name Con- Steel Plastic <br /> New xi-tin, To Tanks Concrete strutted glass App. <br /> Tanks Tanks <br /> Se tic Tankor Holdin Tank <br /> I El <br /> Lift Pum Tank/Siphon Chamber '7S0 f �+* ` ❑ <br /> VII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plan 5. <br /> Plumber's Name(Print): Plumber's Signature:(No Stamps) MP/MPRSW Noo..: usiness Phoney NumbeCry: �7 <br /> Plumber's A dresStreet, i ,State,Zip Code): Nam f Designer <br /> VIII. SOIL TEST INFORMATION <br /> Certi d Soil Tester(CST)Name „ CST# / / �7 <br /> t �f r <br /> CST's ADDR SS(Street,City,State,Zi de) l Phone Nu bar: <br /> W - s 7 f'66- ell r7 <br /> IX COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee Groundwater ate Issuing ent ignature(No Stamps) <br /> q� S rcharge Fee �I //11nn <br /> Approved ❑ Owner Given Initial 'aSo IJV �tC q� c / 'a�-� <br /> Adverse Determination c�Soo ' , <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,Plumb r <br />