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SANITARY PERMIT APPLICATION COI JNTY <br /> DILHR In accord with ILHR 83.05,Wis.Adm. Code <br /> �'•- -� <br /> STi TE SANITARY PERMIT# n <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NOMBER <br /> 8'h x 11 inches in size. <br /> -See reverse side for instructions for completing this application. PE ITION <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. Fo VARIANCE ❑YES ❑ NO <br /> PROP RTY OWNER PROPERTY LOCATION <br /> 2T 64— Y. 3 A, S 7 T-{U N, R J E(or) <br /> PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISI NAME <br /> CITY,STATED ZIP CODE PHONE NUMBER CITY NEAREST AD,LAKE OR LANDMARK <br /> fr7la E t7[� � 7V TOWN OF: JA VILLAGE: r /1J9/ /QQf�1� <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 1112,3 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 it to County Copy. <br /> IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2) <br /> 1. a. KConventional b. ❑Alternative C. ❑Experimental <br /> 2. a. ❑System- b. ❑ Holding cl❑ Pit Privy d. ❑ Vault Privy e.❑ Mound I. U IGP <br /> In-Fill Tank <br /> V. ABSORPTION SYSTEM INFORMATION: (Check one) <br /> 1. a. Rseepage Bed b. ❑Seepage Trench c. ❑Seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. W ER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(^^Square Feet): <br /> �1 � d �7Y.J-Feet ivate El joint ❑ Public <br /> VI. TANK CAPACITYin alions Total #of Prefab. Site Fiber- Exper. <br /> INFORMATION Manufacturer's Name Con- Stee Plastic <br /> New Existing Gallons Tanks Concrete glass App. <br /> Tanks Tanks strutted <br /> Se tic Tank or Holding Tank Tan (�(� • i11�t� r <br /> Lift Pump Tank/Siphon Chamber ❑ El <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): Plum ture:(No Stamps) MP/MPRSW No.: Bu iness Phone Number: <br /> +�a�t�►.� �. r�l2ort T6� o"7a- yv 3sb9 <br /> Plumber's Address(Street,City,State,Zip Code): • Name of Designer: <br /> �r S �c7 ��A i� ,v i �� <br /> VIII. SOIL TEST INFORMATION <br /> Certifi it Tester(CST)Name EPhone <br /> III <br /> U0AG_O L - ROF S <br /> CST's ADDRESS(Street,City,Stale,Zip Code) Numb r: <br /> QT 3 Y°av� Q7o [ � c U01 Y�/- <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved I Sanitary Permit Fee Groundwater ZDe ssuin gent S lature(No Stamps) <br /> Approved ❑ Owner Given Initial S charge Fee -^„ <br /> Adverse Determination <br /> 8C-QOv—ZS.Co vS(J jScj ` /r/QL7t� <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 />