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SANITARY PERMIT APPLICATION "ff;rr(le <br /> tt <br /> (:� DILHR In accord with ILHR 83.05,Wis.Adm. Code <br /> STATE SANITARY PERMIT# <br /> )0 35 (Q <br /> U7) <br /> complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBER <br /> 8'h 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. F09 VARIANCE ❑YES ❑ NO <br /> PROPERTY OWNER PROPERTY LOCATION `!�/,^, _ <br /> 11r C �iCzSG /1'16'/4,nf %, S a7 T VO, N, R E (or <br /> PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME <br /> i7dr. — <br /> CITY,STATE T ZIP CODE PHONE NUMBER CITY NEAREST CAD,L_AKF OR LANDMARK <br /> ff?A6u L / Q� 3 3�� VILLAGE <br /> II. TYPE OF BUILDING OR USE SERVED: �,,/ 'TOS Cl��-CA 7 CJ <br /> Number of Bedrooms if 1 or 2 Family g /rzS 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 AgreeME 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. 9 Seepage Bed b. ❑ Seepage Trench C. ❑ Seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 15.SYSTEM ELEVATION 6. WATER SUPPLY: <br /> (Minutes er inch): REQUIRED,((SS�quare Feet): PROPOSED Sgpare Feet): <br /> 7 ld Feet P ivate ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in allons Total #of <br /> Prefab. LFiber- Exper. <br /> INFORMATION New xi$tin Gallons Tanks Manufacturer's Name Concrete Con- Ste Plastic App <br /> Tanks Tanks ��++ strutted <br /> Septic Tank or Holdin Tank 7XVC ❑Lift Pum Tank/Si hon 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.IN Stamps) MP/MPRSW No.: siness Phone Number: <br /> 7/S <br /> Plumber's Address(Street,City,State,Zip Code): Name of Designer: <br /> f1>rre�: Via. as rr u/r ye d�si� <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name CST# <br /> k//00/f, f holm �3 <br /> CST's ADDRESS(Street,City,State,Zip Code) Phone Number <br /> �SQin 7/S �loG- 7�P <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee Groundwater ate ISSUI Ag nt Si natur ostamps) <br /> Approved ❑ Owner Given Initial `���'}1}..l�}�`�x�,,//�A'� InIn� SSuurcharge Fee {/'I <br /> Adverse Determination <br /> IOU <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 /> _.l.__.... ____.___._....... .. <br />