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^ SANITARY PERMIT APPLICATION COUNTY <br /> L] GILHR In accord with ILHR 83.05, Wis.Adm.Code r <br /> STATE SANITARY PERMIT# <br /> TAT <br /> —Attach complete plans (to the county copy only)for the system,on paper not less than SE PLAN I.D. UMBER <br /> ls <br /> 8'FA 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 /> MI t- b' ,A n 4,Y fill, TW %-C W '/a, S 9 T VON, R E (or W <br /> PROPERTY OWNER'S MAILING ADDRE S LOTNUMBER BLOCK NUMBER SUBDIVISION NAMEI <br /> d 0 s ( d e A/ d 7r_ 1 zs /t4' r1+,p <br /> CITrY,STATE QQ I ZIP CODE PHONE NUMBER CITY / NEAREST R/O D,LAKE OR LANDMARK <br /> WN• MTOWN <br /> VILLAGE : V. Ij�JW <br /> II. TYPE OF BUILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family �— OR ❑ Public(Specify): <br /> III. PURPOSE OF APPLICATION: (Check only one in#1. Check ii 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. X 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): !�' �y <br /> S ( ( -q L -r.3 Feet X Private ❑Joint ❑ Public <br /> VI. TANK CAPACITYlinallons Total #of Prefab. Site Fiber- Exper. <br /> INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks structed <br /> Septic Tank or Hodino Tank * A4 C El ❑ 1:1 ❑ El <br /> Lift Pump Tank/Siphon Chamber ❑ I ❑ ❑ ❑ ❑ ❑ <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 's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> 6 <br /> 0" `Q►ter G rEry` <br /> Plumber' Address(Street,City,State,Zip Code): Nam f Desi ner: <br /> r <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name / CST# <br /> CST's ADDRESS reef ity,State,Zip C e) Phone Number: <br /> r- W '. <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee Groundwater to Iss Agent Signature(No Stamps) <br /> Approved ❑ Owner Given Initial (Nn Se <br /> ��}{�Fharge Fe <br /> Adverse Determination ° <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 />