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[�. SANITARY PERMIT APPLICATION cC TY <br /> LI DILHR In accord with ILHR 83.05,Wis. Adm. Code <br /> S TE SANITARY P i MIT# _ <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than S7 TE PLAN I.D. BER—(1''"nl <br /> 8'fi x 11 inches in size. <br /> —See reverse side for instructions for completing this application. PE ITION <br /> 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. Fo VARIANCE ❑YES ❑ NO <br /> PER WNER� PROPERTY LOCATION <br /> PI <br /> sed S£ '/a NW '/a, S / T yO, N, R / E (or W <br /> PROPERTY OWNER'S MAILING ADDRESS LOTNUMBER BLOCK NUMBER SUBDIVISI NNAME <br /> o ) z - 1_7i] ,rpr 3 /A/A Al A earn <br /> CITY,STATE ZIP CODE PHONE NUMBER CITY NEAREST CAD,LAKE OR LANDIA RK <br /> Iw. S SVI C ❑ VILLTOWAGE -C, f S'�Ivi d/ <br /> 11. TYPE OF BUILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family OR ❑ Public(Specify): <br /> 111. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 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 Agreeff"IE nt 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 See a e Bed b. ❑See a e Trench c. ❑ Seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. W TER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): <br /> 7 , 0 7 �^ D ' Feet ®Private ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Ste I glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or HoldingTank S U L-j C– ❑❑ <br /> Lift Pum Tank/Siphon 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): Plumber's Signature:A4o Stamps) MP/MPRSW No.: B iness Phone Number: <br /> R IN dt,v , c k 44 op _ s I 0 ._ l^ /, IF6 6 .i <br /> Plumber' Addr as.(Street,City,State,Zip Code): Name of Designer: <br /> Uki8 is r' a <br /> Vlll. SOIL TEST INFORMATION <br /> Certified S99iI Tester ST)Na a CST# <br /> � <br /> CST's ADD ESS(Street,City,Statd.Zip Code) Phone Num r: <br /> ul 'e�), TTr w� S lJ I f /, <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee Groundwater ate Issuin a Si nature tamps) <br /> Approved E] Owner Given Initial (J"`(D �/�(/�� rchargeFee�e Ila <br /> "-"-' �, <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,Plumbe <br />