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((��,, SANITARY PERMIT APPLICATION CO>1NTY <br /> Ll DILHR In accord with ILHR 83.05,Wis.Adm. Code urnet� <br /> STATESANITARYP RMIT# <br /> C, <br /> —Attach complete plans(to the county copy only)for the system, on paper not less than STATE PLAN I.D. MISER <br /> 81/2 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 /> PROPERTY OWNER jgiig <br /> �y' am Q 7 / T VO, N, R E (orrD <br /> PROPERTY OWNER'S MAILING ADDRESS 96K0WUMBfiR S 661,V Zo <br /> Ve-?/ b 160J2 xr n X101 h sm do% /?CP, sCITY,STATE / ZIP�C,O/PE PHONE NUMBER NEAREST OAD,LAK OR`LAANDMARK/ /S,IY).0 cS�Y�� W:TOWN OF <br /> Q Oh Zaic, <br /> II. TYPE OF BUILDING OR USE SERVED: ��/Number of Bedrooms if 1 or 2 Family a jb /I0011_3 OR ❑ Public(Specify): <br /> III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) <br /> 1. a. 7'"' 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 Agreeri 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.L1 Pit Privy d. ❑ Vault Privy e. ❑ Mound f. IGP <br /> In-Fill Tank <br /> V. ABSORPTION SYSTEM INFORMATION: (Check one) <br /> 1. a. Xf See a e Bed b. ❑ Seepage Trench c. ❑ seepage Pit <br /> 2. PERCOLATION RATE 13, ABSORPTION AREA 14. ABSORPTION AREA 5.SYSTEM ELEVATION 6. W TER SUPPLY: <br /> (Minutes per inch): REQUIRE/D/(Square Feet): PROPOSED IS are Feet): �J _ <br /> 3 Y/O y�y 7 �J Feet rivate [:]Joint ❑ Public <br /> VI. TANK CAPACITY I Site <br /> in allons Total #ofPrefab. 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 Holdin Tank SO MG Ll ❑ ❑ <br /> Lift Pump 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 oStamps) MP/MPRSW No.: B siness Phone Number: <br /> Q�e ,L�u�s/i0 A)amL 3340/ :7/•S Plolo- 7a PCP <br /> Plumber's Address(Street,City,State,Zip Code): Name of Designer: <br /> LovS6 Teal vd.,5- <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name CST# <br /> Qde .�uhv/rn S�3 <br /> CST's ADDRESS(Street,City,State,Zip Code) Phone Numt er: <br /> L56bnG 7/S PIaG - 7�PlP <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> �j Disapproved Sanitary Permit Fee Groundwater ate Iss g gent Si net r No Stamps) <br /> }�]I Approved ❑ Owner Given Initial N�� Surcharge Fee <br /> I V U<'N as,cro rj' <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 />