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(�, SANITARY PERMIT APPLICATION <br /> Ll �ILHR In accord with ILHR 83.05,Wis.Adm. Code <br /> STATE SANTA,FIY PERMIT <br /> —Attach complete plans(to the county copy only)for the system, on paper not less than STATE PLAN I.D.NUMBER <br /> 8'/A x 11 inches in size. <br /> —See reverse side for instructions for completing this application. PETITION <br /> 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES ❑ NO <br /> PROPERT SOWN RR. t./ PROPERTY LOCATION <br /> C [ / h1 !c nl 1� ( 4 f-/', sl Ya Nfll',n, S �� T.`3 , N, R /7 (or) W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDII I$ION NAME <br /> G'[r le+ 6e A- N <br /> CITY,STATE ZIP CODE PHONE NUMBER CITY NEAREST ROAD,L KE OR LANDMARK <br /> s OO wY w l y9y3 7 63t •89L VILLAGE : J G <br /> 11. TYPE OF BUILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family OR El 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 Agreementto 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. ® Seepage Bed b. ❑Seepage Trench c. ❑ Seepage Pit <br /> 2. PERCOLATION RATE 13, ABSORPTION AREA 14. ABSORPTION AREA 15.SYSTEM ELEVATTvER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet):3 � Feeate ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> M El <br /> Septic Tank or Holdin Tank ��0 Q' ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber I ❑ ❑ <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): Plu er's Signature:( Stamps) MP/MPRSW No.: Business Phone Number: <br /> R J e r E c f ;i 1' A'el�.�-c�1- '!' A (:) J' /S I ` l <br /> PI`u�ber's ddre i <br /> (Street,Cd t� State,Zip Code) Name Desi n r <br /> VIII. SOIL TEST INFORMATION <br /> Cert;' voiyester`SL�T)�me CST# '/ 3 <br /> z 7 <br /> CST's ADDRES (Stye t City,State,Zip Code) Phone Number: <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee Groundwater ate is sui gents; ture(No Stamps) <br /> Surcharge Fee <br /> Approved ❑ Owner Given Initial n _ <br /> Adverse Determination � ` ` $,P <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 />