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(�, SANITARY PERMIT APPLICATION co TM <br /> l] �ILHR In accord with ILHR 83.05,Wis.Adm. Code rn <br /> STATE SANITARY PERMIT# <br /> MEN <br /> -Attach complete plans(to the county copy only)for the system, on paper not less than STATE PLAN I.D.NUMBER <br /> Wx 11 inches in size. <br /> -See reverse side for instructions for completing this application. PETITION <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES LINO <br /> PROPERTY OWNER PROPERTY LOCATION ca <br /> 1 ry S K1 d- -r� vp [. /UW Ya SWY<, S a.d T j1p,, N, R �� @ (or) W <br /> PROP RTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISIION NAME <br /> Q "C /�/'/t- X13-" A <br /> CIT;,tTAT,E ZIP CODE PHONENUMBER by- 17 CITY : NEAREST ROAD,LAKE OR LANDMARK <br /> bt F w` PP3 7�Ir II(�I�T� TOWN VILLAGE: aQ� <., <br /> II. TYPE OF BUILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family OR ❑ Public(Specify): cE A C C 'e <br /> III. PURPOSE OFAPPLICATION: (Check only one in#1. Check#2,3 or 4, if applicable) <br /> 1. a. ❑ New b. L/�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. P§Conventional b. ❑ Alternative C. ❑ Experimental <br /> 2. a. ❑System- b. ❑ Holding c.El Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP <br /> In-Fill Tank <br /> V. ABSORPTION SYSTEM INFORMATION: (Check one) <br /> 1. a. XSeepage Bed b. ❑Seepage Trench c. ❑ Seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOS <br /> ED(S!q�uare Feet),! 9 <br /> 0 0 U V ( 6`- Feet Private ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in allons Total #ofPrefab. Fiber- Exper. <br /> INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank 1;)-dl C).. IN EJ ❑ ❑ <br /> Lilt Pump Tank/Siphon Chamber ❑ ❑ Ll ❑ <br /> VII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Plumber'sp�arae(Printf: Plu s Sig ature:INo St ps) MP/MPRSW No.: Business Phone Number: <br /> a d-e t^r c r �rn r 3 e s /& 966 /s <br /> Plumber's dress Street,City,State,Zip Code): Naffwgf D si ner: <br /> Vlll. SOIL TEST INFORMATION <br /> Cad Soil Tester(COST)Name <br /> re Zip Code) CST# <br /> W� r! C z <br /> CST's ADDRESS(S reet,City,State, Phone Number: <br /> LM <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved �,Shha--nitary Permit Fee Groundwater ate Iss Agent Si ture(No Stamps) <br /> Approved ❑ Owner Given Initial �tl,I n ,tb� Surcharge Fee 4a <br /> X. <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 />