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SANITARY PERMIT APPLICATION <br /> DIL�-IR TY <br /> -r- <br /> _ In accord with ILHR 83.05,Wis.Adm. Code <br /> S TESANITARYRMIT# <br /> 33q <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than PS TE PLAN I.D.N BER <br /> 8'%x 11 inches in size. <br /> —See reverse side for instructions for completing this application. PE TITION <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. F R VARIANCE ❑VES ❑ NO <br /> PROPERTYOWNERPROPERTY LOCATION <br /> 9&-4:T <br /> r L 5 w'/451/a, S T , N, R 10Z E (or <br /> PROPERTY OWNER'S MAILING ADD LOTNUMBER <br /> BER BLOCK N MBER SUBDIVISION NAME <br /> .5 Gv�sr �7: /lA/f� 4 <br /> CITY,STAT ZIP CODE PHONE NUMBER CITY NEAREST CAD,LAKE OR LANDMARK <br /> A/ VILLAGE:�`G L) CL M K <br /> / n/ <br /> IL TYPE OF BUILDING OR USE SERVED: t L <br /> Number of Bedrooms if 1 or 2 Family :0' OR ❑ Public(Specify): <br /> Ill. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) <br /> 1. a. New b. ❑ Replacement c. ElReplacement of d. ❑ Reconnection of e ElRepair 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 Agreem4 int to County Copy. <br /> IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2) <br /> 1. a.gConventional 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. Seepage Bed b. ❑Seepage Trench c. ❑ Seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. Wj kTER SUPPLY: <br /> (Minutes er inch): REQUIRED(Square Feet): PROPOSED(Square Feet): / // <br /> G' (/ /O 77 Feet ZPrivate El joint ❑ Public <br /> VI. TANK CAPACITYin allons Total of Prefab. Slte J]PIasitic Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel App <br /> T nks Tanks strutted <br /> Septic Tank or Holding Tank <br /> Lift Pump Tank/Siphon Chamber I ❑ <br /> VII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the private sewage system sho n on the attached plans <br /> Plumber's Name(Print): Plu a 's Si ture:{No Stam MP MPRSW No.: Business Phone Number: <br /> sibs �s gds-y6 <br /> PI ber's ddress(Street,City,Stale,Zip Code): Name of esigner: <br /> 7'E GcJi . SY I- vlAl s <br /> Vlll. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name21�L Uig CST# / <br /> CS 's ADDRESS(Street,City,State,Zip Code) CJ Phone Numb r: <br /> Z wE SrEiP was, s�8 '7is X66- SS <br /> IX. OUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee I Groundwater ate Is n Agent Si toe(No Stamps) <br /> Approved ❑ Owner Given Initial J((` Surcharg77e��FFenee <br /> Ativerse Determination ` co <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 />