Laserfiche WebLink
SANITARY PERMIT APPLICATION COUNTY <br /> D1LHR Iri accord with ILHR 83.05,Wis.Adm.Code fir' <br /> STATE SANITARY <br /> //FERMI T#77 <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBER <br /> 8'/z 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 /> rt, L Q JUf_ '/4 d'W '/4, S 3 3 TY0 , N, R /� 8 (or)W <br /> PROPERTY OWNER'S MAILIN ADDRESS LOT NUMBER I BLOC;NUMBER SUBDIVISION NA�1E <br /> CITY, TAT ZIP CODE PHONE NUMBER CITY /�/V%1 NEAREST RROOAD,,LAKE OR LANDMARK <br /> SYF93 0 VILLAGE: Q 9/1 CVA d 35— <br /> II. TYPE OF BUILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family OR ❑ Public(Specify): S'#o w r r <br /> III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) <br /> 1. a. K 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#t and only one in#2) <br /> 1. a. ❑Conventional b.�K Alternative C. ❑ Experimental <br /> 2. a. ❑System- b. ❑ Holding C.Ll Pit Privy d. ❑ Vault Privy e. 9 Mound f. ❑ IGP <br /> In-Fill Tank <br /> V. ABSORPTION SYSTEM INFORMATION: (Check one) <br /> 1. a. ® seepage Bed b. ❑ Seepage Trench c. ❑ See a e Pit <br /> 2. PERCOLATION RATE 13. ABSORPTION AREA 14. ABSORPTION AREA 15.SYSTEM ELEVATION 6. WATER SUPPLY: <br /> ' <br /> (Minutes per inch): REOUI RED(Square Feet): PROPOSED(Square Feet): 133 <br /> 3 ,Ss'' <br /> 7 SU O , 17' Feet K`s Private ❑Joint El Public <br /> VI. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION Manufacturer's Name Con- Steel Plastic <br /> New xisting Gallons Tanks Concrete strutted glass App. <br /> Tanks ITanks <br /> Septic Tank orHoldin ank TX &7S W G <br /> Lift Pum Tank/Si hon Chamber /30 t W G El <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'sSignature (No Stamps) MP/MPRSW No.: Business Phone Number: <br /> /� o d'e r•/e }�o fir n S D 3 o j 9 ]/r ?(P4%V/s7 <br /> Plumber's Address(Street,City,State,Zip Code): Naf�e of Designer: <br /> LAJ 7—,e C L-., <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name / CST <br /> e <br /> 5 # <br /> e J7JU�'Of b�.NS <br /> CST's ADDRESS(Scree,city,State,Lip Code) Phone Number: <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee Groundwater at Issui gent Signature(No Stamps) <br /> Approved ❑ Surcharge Fee <br /> Owner Given Initial r <br /> Adverse Determination <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 />