Laserfiche WebLink
SANITARY PERMIT APPLICATION C LINTY <br /> LDILHR In accord with ILHR 83.05,Wis.Adm.Code �`J <br /> STATE SANITARY ITARY P i IT� <br /> q12 <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBER <br /> 8'/x 11 inches in size. <br /> —See reverse side for instructions for completing this application. PETITION <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. I FOR VARIANCE ❑YES ❑ NO <br /> PRO��P.-E--RJ/7YOWNE tt PROPERTY LOCATION ty <br /> Gd.tu,l 7 to4P-Dt I kc Sr. Sle%SLAJ 1/4, SI T13 , r1, R <br /> PROPERTY <br /> trOV[YN_ER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME <br /> ttc� ItV� <br /> CITY,STATE I ZIP CODE PONE NU ER VILLAGE: NEAR,5T ROAD AK R LANDMARK <br /> Cr�s1c 1�1 : o �^ <br /> IL 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. IX 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. R9 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 Seepage Bed b. ❑Seepage Trench c. ❑ See a e Pit <br /> 2. PERCOLATION RATE 13. ABSORPTION AREA 4. ABSORPTION AREA 5.;7SYSTEM ELEVATION 6. WATER SUPPLY: <br /> (� (Mi utes per inch): RE UIRED(Square Feet): PROPOSED(Square Feet): Icy1 — W— ( � ZCi l Feet LT+Private ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> I <br /> all Ty <br /> Total #of Manufacturer's Name Prefab. Con- Steel Fiber- plastic Exper. <br /> INFORMATION New mating Gallons Tanks Concrete glass App. <br /> Tanks Tanks strutted <br /> Septic Tank or HoldingTank l VyeS.tC6 ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ ❑ <br /> VII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for iqttallation of the private sewage system shown on the attached plans. <br /> Plumber's Name(Print)- Plu r's Sature: o amps) MP/MPRSW No.: Business Phone Number: <br /> -Ws Koge r te tizl <br /> /V 7 t/ "J <br /> Plumber's Address(Street,Ci y, tat Zip Code): Name of Desi ner: <br /> VIII. SOIL TEST INFORMATION <br /> Certiji3d Soil TesterO a-7 <br /> ic �v, f �/ <br /> 3 <br /> CSTss DDRESS(Street,City,Stat Zip,Code) Phone Number: <br /> Z, 4.(LtiS�r _y ( 7/ S 3YS-�9iv <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee Groundwater ate IssuingA nt Signature(No Stamps) <br /> Approved ❑ Owner Given Initial S charge/FFeee1 <br /> Adverse Determination <br /> X. COMMENTS/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.03/86) CcirRIBUTION. Original to County.One Copy To:Bureau of Plumbing,Owner,Plumber <br />