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SANITARY PERMIT APPLICATION COUNTY <br /> O 3IL.HR <br /> In accord with ILHR 83.05,Wis.Adm.Code STATE SANITA Y PERMIT# <br /> O <br /> —Attach complete plans(to the county copy only)for the system, on paper not less than STATE PLAN I.D.NUMBER <br /> 8'h x 11 inches in size. <br /> —See reverse side for instructions for completing this application. PETITION <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES ❑ NO <br /> PROPERTY OWNER � PROPERTY LOCATION <br /> r t/4 1� 4, S T c1l, N, R <br /> PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME <br /> -2 ^`� 5 1>7zC9r«,A6< 9A!>. <br /> CITY,STAT ZIP C E PHONE NUMBER/ CITY NEAREST ROAD,LAKE OR LANDMARK <br /> —S� b/Z K BE VILLAGE BEKTOWN : 5CV/S <br /> II. TYPE OF BUILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family OR 1-1 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 Agreement 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. Seepage Bed b. ❑Seepage Trench c. ❑ Seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): /- r 'Feet Private ❑Joint ❑ Public <br /> VI. TANK CAPACITY I Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass iEl <br /> App <br /> _TT <br /> Tanks Tanks strutted <br /> Septic Tank or HoldingTank T/✓J - ❑ <br /> Lift Pum Tank/Siphon Chamber ❑ ❑ <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): PI er'a S' atur :( MP/MPRSW No.: Business Phone Number: <br /> i/- <br /> Plumber's Address(Street,City,State,Zip Code): Name of Designer: <br /> k t 3 - 20 D97,< <br /> VIII. SOIL TEST INFORMATION <br /> Certifie oil Tester(CST) CST# <br /> Nye.e �/2 t-T- <br /> CST a ADDRESS(Street,City,State,Zip Code) p Phone Number: p� <br /> © K t49 l O �� d-• �— <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved I Sanitary Permit Fee I Groundwater Pate Issu gA ent Signalur lamps) <br /> Approved ❑ Owner Given Initial 60-� S argeFFee <br /> Adverse Determination lJ ,in L <br /> X. COMMENTS/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)in,03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber <br />