Laserfiche WebLink
SANITARY PERMIT APPLICATION co NTY <br /> 7 DILHR In accord with ILHR 83.05,Wis.Adm.Code Uf J ej(_�_ <br /> STATE SANITARYPERMIT <br /> -Attach complete plans(to the county copy only)for the system, on paper not less than STTAA ITE PLAN I.D.NUMBER <br /> '``IIf <br /> 8'%x 11 inches in size. <br /> —See reverse side for instructions for completing this application. PETITION <br /> 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. F FOR VARIANCE ❑VES ❑ NO <br /> PR PERK OWNER LLEOT <br /> RTY LOCATION <br /> �� ,gyp /- �.tf '/a S� 't/a, S too' T �0, N, R � f{et W <br /> PROPERTY C ryER'O�L' GAD 4ES$ MBER BLOCK NUMBERt 0 EZIPO0DE PHONE NUMBER Y .�.,LNErAIRESTROAD A RLAN MARK <br /> 7WL TOWLAGE ; SGO/ I 1 C el-1 l k2 <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. ® 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. N 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. ABS RPTION SYSTEM INFORMATION: (Check one) <br /> 1. a. Seepage Bed b. ❑ Seepage Trench c. ❑ Seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 14. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: <br /> (,M'inute's/per inch): RE'Q'UIRED(Square Feet): PROP'O'SED(Square Feet): i <br /> Z — 7 7�o 7 -1.-n ?,;? I Feet Private ❑Joint ❑ Public <br /> CAPACITY VI. TANK CSite <br /> in gallons Total #ofPrefab. Fiber- Exper. <br /> INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks I Tanks strutted <br /> Septic Tank or Holding Tank X '7Sa I I tote5et- s..C/W P <br /> Lift Pump Tank/Siphon Chamber X " " ❑ ❑ <br /> VII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for'nstallation of the private sewage system shown on the attached plans. <br /> Plumber's Name(Print): Plu tier's ' nature:( St ps) MP/MPRSW No.: Business Phone Number: <br /> At/Wsof Jr r IVPS7d'41 <br /> Plumber's Address(Street,City,Stalg Zip Code): Name of Designer: <br /> VII. SOIL TEST INFORMATION <br /> CertifieS 1 Tester(CST)Name EPhone <br /> T# <br /> AL1 Sf� �/ <br /> CST's ADDRESS(Street,City,State,Zip Code) Number: <br /> �. v -7S- 3Vf- a4 F <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee Groundwater ate Issuing Writ Signature(No Stamps) <br /> Approved ❑ Owner Given Initial ///y^' ���(7�) r=rrge/�Ffee /�, <br /> Adverse Determination ` 0,0 '^- ,0 -�-�� <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 />