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SANITARY PERMIT APPLICATION COUNTY <br /> I�Y DILHR In accord with ILHR 83.05,Wis.Adm.Code <br /> STATE SANITARY ERMIT# <br /> a <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 /> 0 9 if 46e 1. 710 ]NE '/a ''/a, S S? Ted , N, R /� a (o W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK N MBER SUBDIVISION NAME <br /> G A ,v uY� r q/ N <br /> CITY, T TE ZIP CODE PHONE NUMBER CITY NEAREST ROAD,LAKE OR LANDMARK <br /> U J S HI ) o� O VILLAGE .0f t.lf/', U'Cr GF S <br /> 11. 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. ❑ New b. p 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. X 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. 251 See a e Bed b. ❑seepage Trench C. ❑ Seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 15.SYSTEM ELEVATION 6. WATER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): <br /> 93 r Feet Private ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in gallons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- plastic Exper. <br /> INFORMATION New xisting Gallons Tanks Concrete glass App. <br /> Tanks Tanks structed <br /> Septic Tank or Holding Tank X 7S'G 1 1 7-A4 C. I Lj I L1 ❑ El <br /> Lift Pump Tank/Siphon Chamber Li 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): Plum ' Signature:p(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> 6�� ;� f; a h�►is a4 0 a /.r X66 it <br /> Plumber's Address(Street,City,State,Zip Code): Name of Designer: <br /> VIII. SOIL TEST INFORMATION <br /> Certi 'ed4 it Test J( ST)Name S CST <br /> /// Q cL/ � J <br /> CST's ADDRESS(Street,City,State,Zip Code) Phone Number: <br /> (uti4=Tr w` , s 3 s- Bim. yes <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved I Sanitary Permit Fee Groundwater Date Is i Agent Sign (No Stamps) <br /> A roved S rcharge Fee <br /> pp ❑ Owner a Determination �\ <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 />