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OILHR SANITARY PERMIT APPLICATION o D <br /> urriett- <br /> In accord with ILHR 83.05,Wis.Adm. Code <br /> STATE SANITARY PE MIT# <br /> r <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NOMBER <br /> 8'h x 11 inches in size. <br /> —See reverse side for instructions for completing this application. PE TITION <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES ❑ NO <br /> PROPERTYO NER PROPERTY LOCATION <br /> rt S7f- <br /> 0.16 <br /> Sul '/4 N W '/4, S 11 T39, N, R /y V(or) W <br /> P OPERTY OWNER'S MAILING ADDRESS LOTNUMBER BLOEa <br /> NNAME <br /> C o L-o Ar v .7 T. Rt Bex Al <br /> CITY,STATE ZIP CODE PHONE NUMBER CITY CAD,LAKE OR LANDMARK <br /> O Otite 1— W ❑ VILLAGETOWN : G <br /> 11. TYPE OF BUILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family OR ❑ Public(Specify): <br /> 111. 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 Agreem4 Int to County Copy. <br /> IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2) <br /> 1. a. [9 Conventional b. ❑Alternative C. ❑ Experimental <br /> 2. a. ❑System- b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. El IGP <br /> In-Fill Tank <br /> V. ABSORPTION SYSTEM INFORMATION: (Check one) <br /> 1. a. X Seepage Bed b. ❑Seepage Trench C. ❑ See a e Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. W TER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet):.3 4yf <br /> C dq 3 X9725 ! .1' Feet ❑F rivate ❑Joint ❑ Public <br /> VI. TANK CAPACITY <br /> Incallons Total #of Prefab. Site Fiber- Exper. <br /> INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Ste glass Plastic App <br /> Tanks Tanks structed <br /> Septic Tank or Holdina Tank S6 I W G ❑ <br /> Lift Pump Tank/Si hon Chamber L I L ❑ <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): Plum Signature'(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> ti D,� 0 S9 <br /> Plumber's Addr ss(Street,City,State,Zip Code): VName of Design r: <br /> Vlll. SOIL TEST INFORMATION <br /> Cer'fiedS iI Tester( ST)Name ,,// CST# <br /> pet C <br /> CST's ADDRESS(St eeteet,City,State,Zip ode) Phone Num r <br /> l r p � - ��/ l P U0 '01J`7 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> �Iq/1 ❑ Disapproved Sanitary Permit Fee Groundwater Is in Agent Si Ina re No Stamps) <br /> ILYApproved ❑ Owner Given Initial QI`C�n /�'1 S charge Fee [afe <br /> Adverse Determination c � -� IRSoco <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,Plumber <br />