Laserfiche WebLink
�tLHR SANITARY PERMIT APPLICATION cc <br /> Y <br /> In accord with ILHR 83.05,Wis.Adm.Code <br /> ST TESANITARY ERMIT# <br /> 13 <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ST TE PLAN I.D. UMBER <br /> 8'h x 11 inches in size. <br /> -See reverse side for instructions for completing this application. PETITION <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. FC R VARIANCE ❑YES ❑ NO <br /> PROPERTY OWNER PROPERTY LOCATION <br /> 4f L ra SW '/4SW '/4, S ap T ON, R S— ! (or W <br /> PROPERTY OWNE 'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISI N NAME <br /> 'F I Al A, br <br /> CITY, TATE ZIP CODE PHONE NUMBER CITY TOWN NEARE T OAD,LAKE OR LANDMARK <br /> W S ❑ VILLAGE : C W /I 1 <br /> It. TYPE OF BUILDING OR USE SERVED: C <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. *New b. CKReplacement 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 Agreem 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. Seepage Bed b. ❑Seepage Trench c. ❑Seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. W TER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): 1�I <br /> C �C 7-- 9 /' ' Feet ISI P ivate ❑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- Ste glass Plastic App <br /> Tanks Tanks structed <br /> Septic Tank or Holding Tank7 1 ElEl ElLift Pump Tank/Siphon 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): Plu 's Signature: No Stamps) MP/MPRSW No.: Bu 5iness Phone NumberRr& : <br /> ' 1`IC <br /> Plumbers Address(Street,City(State,Zip Code): IN f Design r: <br /> uM� <br /> Vlll. SOIL TEST INFORMATION <br /> Certified Soil ester(C T)Name CST# <br /> C / Slo <br /> CST's DDRSS( treet,City,State,ZI Code) Phone Numb r: <br /> e t G S d? G —tu COUNTY/DEPARTMENT USE ONLY <br /> E] Disapproved Sanitary Permit Fee Groundwater r ateIss5ey Agent Si na (No Stamps) <br /> Approved ❑ Owner Given Initial �`,n�/Y/� SSu}rcharge/Fee <br /> Adverse Determination `tP <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 />