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SANITARY PERMIT APPLICATION C7O.��NTY {�-_-- <br /> OILHR In accord with ILHR 83.05,Wis.Adm.Code f�JU�f12 <br /> fC v STATESANITARY ERMIT#3 <br /> // /T/ <br /> _) <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 /> 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES ❑ NO <br /> PROPERTY OWNER PROPERTY LOCATION <br /> DE /V ; O/2 64 % 7 '/4, S /3 T'/O, N, R y6 E (orQD <br /> PROPERTY OWNER'S MAILIN ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME <br /> �' A X89 3 S v,¢ P/ l�tx S/-JOR4 <br /> CITY,STATE ZIP CODE PHONE NUMBER CITY NEAREST ROAD,LAKE O LANDMARK <br /> y�6 VILLAGE : <br /> 11. TYPE OF BUILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family - OR ❑ Public(Specify): I. <br /> III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) <br /> 1. a. FXNew 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.NConventional b. ❑Alternative c. ❑ Experimental <br /> 2. a. ❑System- b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f.I❑ 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. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: <br /> (Minutes per REQUIRED(Square Feet): PROPOSED(Square Feet): 11 <br /> Feet t5JPrivate El Joint ❑ Public <br /> VI. TANK CAPACITY I <br /> Site <br /> in ga ons Total #ofPrefab. Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Ste@I glass Plastic App <br /> Tanks Tanks strutted <br /> Se tic Tank or Holding Tank <br /> Lift Pum Tank/Si hon Chamber ❑ I Ll ❑ ❑ ❑ <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 nature:(No tam s MP/MPRSW No.: BQIamass Phone Number: <br /> A,rvA9 , > _ y 0J - 3072 7..i zsC/ 350 <br /> Plumber's Address(Street,City State,Zip Code): Name of Designer: <br /> k2 7 �m 7 O <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name CST# <br /> CST's ADDRESS(Street,City,State,Zip Code) Phone Num bar: <br /> /q 7 3 V7 ) 0/- `zl`d 3 e� 71L <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee Groundwater ate Is ing Agent Sil7nature(No Stamps) <br /> Approved ❑ Owner Given Initial VDI�JI_1r�V S-off rch� F�e�e, , I C� � n�A.` - � <br /> Adverse Determination o�J IJ IJ �j�J X <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 />