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SANITARY PERMIT APPLICATION COUNTY <br /> (�I DILHR In accord with ILHR 83.05,Wis.Adm. CodeurrlZO:-,- <br /> _ <br /> STATESANITARY ERMIT# <br /> ugSlv 137 <br /> -Attach complete plans (to the county copy only)for the system, on paper not less than STATE PLAN I.D.NUMBER <br /> 8%x 11 inches in size. <br /> -See reverse side for instructions for completing this application. PEI ITION <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. FOF I VARIANCE ❑YES ❑ NO <br /> PROPERTYOWNER PROPgRTYLOC/ATION ,/ <br /> 00 <br /> GQi?Unke/ 51< '%NW'/a, S o�7 T 7xd, N, R E (or <br /> PF16PERTY OWNER'S MAILING_ADDRESS LOT NUMBER I BLOCK NUMBER SUBDIVISION NAME <br /> �. . <br /> CIT4, A2Y <br /> %,STAT �1 ZIP G DE 1 PHNl1nBER- VCITY ILLAGE : /li.�O N &6,7 R AD,LAKE OR LANDMARK <br /> If. TYPE OF BUILDING OR USE SERVED: % !(� C/U C, C <br /> Number of Bedrooms if 1 or 2 Family o? 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 Agreeme it to County Copy. <br /> IV. TYPE <br /> ,�O,Fr SYSTEM: (Check only one in#1 and only one in#2) <br /> 11SI <br /> 1. a. Conventional b. El Alternative c. El Experimental <br /> 2. a./❑System- b. ❑ Holding c.El 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 See a e Bed b. ❑ Seepage Trench c. ❑ Seepage Pit <br /> 2. PERCOLATION RATE 13. ABSORPTION AREA 14. ABSORPTION AREA 5.SYSTEM ELEVATION 6. W TER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): (�/ <br /> /Q ZaAo 7 , / Feet P ivate ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New misting Gallons Tanks Manufacturer's Name Concrete Con- Ste I glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdin Tank 7S� ❑ <br /> Lift Pum Tank/Si hon 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): Plumber's Signature:(No Stamps) MP/MPRSW No.: Bu mess Phone Number: <br /> I,c/Qde s/b/rri7/5 BIG-7o7�' <br /> Plumber's Address(Street,City,State,Zip Code): Name of Designer: <br /> D e.�S. D e6si I P�23 /�1de16Jk12,QA7 <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name CST# <br /> {.sho/m <br /> CST's ADDRESS(Street,City,State,Zip Code) Phone Number: <br /> 15prne /SPGIn-9aPlp <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee Groundwater ate 21� Issu g ent Si natur N Stamps) <br /> Surcharge Fee <br /> 14 Approved ❑ Owner Given Initial C'�n e� ��, r �- �_ <br /> Adverse Determination OU (JO <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 />