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SANITARY PERMIT APPLICATION C UNTY <br /> Z DILHR In accord with ILHR 83.05,Wis.Adm.Code 6Yn <br /> ommmmm STATE SANITARY RM IT# <br /> 9-7is 1 <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than S FATE PLAN I.D.NUMBER <br /> 8'%x 11 inches in size. <br /> —See reverse side for instructions for completing this application. <br /> P TITION <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. F R VARIANCE ❑YES ❑ NO <br /> P OPERTY OWN�ER� PROPERTYLOCATION <br /> Ll N IF F,, Bove �r-L(L /NG /VE%4`S6114, S /6, T �, N, R tiatto <br /> PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVIS ON NAME <br /> K 1" <br /> CITY,STATE. V ) ZIIP`CQQE PHONE NUMBER 7� LJ CITY NEARES OA ,LAKE OR LANDMARK <br /> �7/0C3Ja 7/,S 2J -3 63 VILLAGE : [. <br /> II. TYPE OF BUILDING OR USE SERVED: 2 <br /> Number of Bedrooms if 1 or 2 Family J OR ❑ Public (Specify): <br /> Ill. 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 Agreement 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. 0 IGP <br /> In-Fill Tank <br /> V. ABSORPTION SYSTEM INFORMATION: (Check one) <br /> 1. a. N Seepage Bed b. ❑Seepage Trench c. ❑ Seepage 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): <br /> .2- a-- � 61s 63� qa, s p <br /> Feet IPI ivate ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> j;p <br /> Total #of Prefab. ber- Exper. <br /> INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Ste I glass Plastic App structed <br /> Septic Tank or Holding Tank X00 (P$i�/- Cre ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ <br /> VII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for 1 stallation of the private sewage system shown on the attached plans. <br /> Plumber's NamePrint): PI u er's nature: o amps) MP/MPRSW No.: Bu iness Phone Number: <br /> /UPAS �oF <br /> Plumber's Address(Street,City,State,Zip Code): Name of D signer: <br /> f v (�s f- a Sy 3 it✓Pts' opv <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name CST# <br /> NE v� 00 S7 <br /> CST's ADD ESS(Street,City,State,Zip Code) Phone Number <br /> 13 oX. s�;o t,)eb6 �� Ccits ��3 a / <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sa tary I'll rmi[Fee Groundwater ate Is gAgent Signature(Non Stamps) <br /> Approved ❑ Owner Given Initial S c^h�argegF�ee -,/— <br /> ////// <br /> Adverse Deter urination ��� "1�� 11i�wr'4C <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 />