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SANITARY PERMIT APPLICATION CO, TY <br /> DILHR In accord with ILHR 83.05,Wis.Adm.Code r <br /> STATE SAN ITARYP RMIT# <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBER <br /> 8'/A 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 /> PROPERTYOWNER PROPERTY LOCATION <br /> �V '/a L07- , S / T yQ, N, R E (orap <br /> PROPERTY OWNER'S MAILINGADDRESS LOTNUMBER BLOCK NUMBER SUBDIVISION NAME <br /> a S i s�E 8k a— N A <br /> CITY,STATE ZIP CO E PHONE NUMBER CITYj Q NEAREST'ROAD,LAKE OR LANDMARK <br /> to <br /> VILLAGE: <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#2,3 or 4,if applicable) <br /> 1. a. NSew b. ❑ Replacement c. ❑ Replacement of d.❑ Reconnection of e.❑ Repair of an <br /> ystem 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.AConventional b. El Alternative c. El 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. PERCOL TION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Squar Feet): / /� <br /> ylO 97' Feet Private ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Expp. <br /> INFORMATION Manufacturer's Name Con- Steel Plastic <br /> New xistin Gallons Tanks Concrete strutted glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank 750 / T�` ❑ <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): Plu ature:(N tam MP/MPRSW No.: r(us7�,s,-j <br /> Number: <br /> E �� so X07v 3soy <br /> Plumber's Address(Street,City,State, ip Code): ` Name of Designer: <br /> /2T o i G<I its 5�1m� <br /> Vlll. SOIL TEST INFORMATION <br /> Ce r d Soil Tester(CST)Eame CST# / ) <br /> Nfl2� �. RC T *(a <br /> CST's ADDRESS(Street,City,State,Zip CoQg)I ` l.l./� Phone Number: <br /> (t k, . 3 X LIJ, /s -350 <br /> cf <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee Groundwater ate Issuing Agent Signature(No Stamps) <br /> S rcharge Fee Y, / V <br /> Approved ❑ Owner Given Initial 1<r1,5 <br /> Adverse Determination W VV or vV <br /> X. COMMENTS/REASONS FOR DISAPPROVAL: <br /> SBC-63981formerly Plb-67)IF,03/86) DISTRIBUTION: Original to Courtly,One Copy To:Bureau of Plumbing,Owner,Plumber <br />