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SANITARY PERMIT APPLICATION c NTY <br /> 7 0ILHR In accord with ILHR 83.05,Wis.Adm.Code v rn e f4- <br /> S.e,.,�...e.,..�,�� STA/rT�ESANITARY P MIT# <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMB, <br /> 8'fz x 11 inches in size. <br /> -See reverse side for instructions for completing this application. PEI ITION <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES ❑ NO <br /> PERTY OWNER \ PROPERTY LOCATION <br /> QY\ JO PLL. NL( /a, Sc) I TS�, N, R 1 W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISI N NAME <br /> _0 <br /> TY,STA E t ZIP CODE PHONE NUMBER CITY (' NNEARE A ,LAKE OR LANDMARK <br /> Z Z (] VILLAGE O e "' " <br /> �Ogj TO <br /> 11. TYPE OF B101 DING 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 Agreemerit to County Copy. <br /> IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2) <br /> 1. a. XConventional 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. See a e Bed b. ❑Seepage Trench c. ❑ Seepage Pit <br /> 2. PER OLATION RATE 3. ABSORPTION AREA 14. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: <br /> (Minutes per inch): REQUIRED /S- Cj <br /> UIRED(Square Feet): PROPOED(Square Feet): / <br /> 3- � CO( D-Q / l # l Feet P ivate El joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Stee glass Plastic App <br /> Tanks Tanks structed <br /> Septic Tank or Holdino Tank �ft0 1 ex-n- C4-wicir 4- <br /> Liftift Pump Tank/Siphon Chamber ❑ ❑ <br /> VII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for nstallation of the private sewage system shown on the attached plans. <br /> Plumber's Name(Print): Plu tier's S' atur (No tamps) MP/MPRSW No.: Business Phone Number: <br /> SIS er JP 778'Y <br /> Numb s Address(Street,City Stale, Co a) Name of De igner: <br /> rV-e�S I <br /> VIII. SOIL TEST INFORMATION <br /> Cert fie Soil Tester(CST N me <br /> CST' AIITTpDR (Street,City,StateZip dB) I � , / � � Ph-7 umb r: <br /> IX. COUNTY/DEPARTMENT USE ONLY S <br /> ❑ Disapproved I Sanitary Permit Fee Groundwater ate IssuinSl/gent Si ul�ture(No Stamps) <br /> Approved ❑ Owner Given Initial GL1 GIA fC�l S ra.5ge�Fee J ��.( ,,,_- _ / -yy7 �) <br /> Adverse Determination �•I� UV (✓,l-J dUa/ .X.1Lf�`n'-�C/ <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 />