HomeMy WebLinkAbout020-1045-30-000
3
mmmom" SANITARY PERMIT APPLICATION
DILHR In accord with ILHR 8105, Wis Adm. Code C R- MX_
AITF-SANIrARYPEFMI -,ty
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-Attach complete plans Ito the county copy only) for the system. on paper nor':ess than SIArE PLAN LD. NUMBER 1
8th x 1' inches in size.
-See reverse side for instructions for completing this application. PETTION
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. FOR VVAIMANCE ~ YES XNo
PROPERTY OWNER PROPEPT'f LOCATION
S T . N, R E (or) -W
PROPERTYOWNER'SMAILING ADDRESS LO-NUMBER BLOCK NUMBED j SUBDIVISICN NAME j
CCY, STATF L'P CCL'E PHONE NUMBER CITY NFAPFST, LAKFCP _ANDg7APk
O VILLAGE
F
It. TYPE OF BUILDING OR USE SERVED:
Number of Eecrooms it 1 or 2 Family OR L- Public (Specify!.
III. PURPOSE OF APPLICATION: Check only one •n #I Check 0 2. a or 4, d apPlicaelei
1 a New I, Replacement G 7 Replacement of d _I Heconnectien of a L_ Repair of an
of System System Septic Tank Only an Existing System Fxisting System
2. A Sanitary Permit was previously issued. Permit # Date Issued
3. An Fxisting System has beer. mspectec and soil condificns meet m nir,um requirements
j A The System is shared by more than one owner'building. Attach Comrncn Ownership Agreement to County Copy
IV. TYPE OF SYSTEM: !Check only ene it and only cne in #2)
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1. a Cerver ,cral b __j Alternative
2. a. System- b 1 Holding C.L Pit Privy d. J VauIt Privy a-'LJ Mounc I L_I IGP
In-Fill Tank
V. ABSORPTION SYSTEM INFORMATION: (Check one)
I. a Sce n3e Red, _b. Secoa e Trench c Li seepage Pit
2. EHCOLAI ION RATE 3 ARSORP ION AREA 4. ABSORPTION AREA 5. SYS-"EM ELEVATION 6. WATER SUPPLY
Mmules w .nch'. FEOUIHEU tSOuare Feel)PROPOSED Square Feet).- -
Feet L- Private G' Joint PCDIic
VI. TANK Tonal Prefa FiberExper
Lan CITY Site
Name on- Ctcel astlC
INFORMATION xisan Gallons Tanks n:ass ADG
9~ 7rlred
Tanks
Seprc lank w dcld rg v'tk
Lillt nr 1"nk: Shon Chenibar L._. U _ L_ 'L~ ,
VII. RESPONSIBILITY STATEMENT
I. in uncemigoed assurlgresponsihdity for urstallancn of the private sewage System shown u, the a,-taCnCC Plans ,
P'w L Nu ne Prrq. ~~i~"/ `uriheir S,gnalure:!No Stampo MP NPq Sw N., Pusmusc Phone Nuni
Pt~P'IH' s Addru59 (mod :;M1Y. Stale, ?-XCCdet. Vame of 0e.S:goef.
VIII. SOIL TEST INFORMATION -
'::a^d:ec Soy' -ux:r•r .CSI; Nerve C;T ~
Phonu Numoei
s AL,CRE_:5 SIrt1A Gilt'. ,`l:dq. +lip lcdul
i )
IX. COUNTY/DEPARTMENT USE ONLY
1 ~ In rtarv Parmr Fie ~n unnwater afu _ s.i nq Agent Slgnalure Nu 3rrmpsl
wchanfe. Fee
i 4yr n,vrC _ d,-, , n Initial
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X. COMMENTS/REASONS FOR DISAPPROVAL:
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1„ REPORT ON SOIL BORINGS AND ""111:11
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PIIIIi ,.1."
PERCOLATION TESTS (115) ANION x,;"°"
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PROFIL OFSCRIPI IONS
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REPORT ON SOIL BORINGS AND PERCOLATION TESTS
WISCONSIN DEPARTMENT OF UFALTH AND SOCIAL SFIIVICES
G P.U. BOX 309, MADISON, WISCONSIN 53701
OCATION: J~=_. GG/'.. &IChonIf-_.T~YN.R~Il for Township of M4niclMlily /I,r U^r _
ol No . Hl-Pk No. C w oy
-1 WTuon Ram? '
nvnxl YvH4y... Name: E' yak/
bihlly A,hl,x.c~J.4"r! /~~•z/>'J- - 7tLll.._ l6j<,s• S Cam- I
- YPF Of OCCUPANCY: INOdenLw X - No.o1fM<Irnrnn+_/_COMMEKCIAL__.__.. -
.FFLUFNT INSPOSAI SYSTFM: NEW X REPLACFMFNT ALTFRNATE SYSTF M_. - UrHER
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_PP IICOLATION 7fSIS
1ATFSOUSERVATIONSMADE. SOILBORINGS__ ALL
'.OII MAPSHFFT NAME Of Sol[ IAAP UNIT
' PFRCOLATION TESTS
TCSI - HMIRS 1VA I"I IN TEST OME
NO n<IP IN WAIEII LCVFI INI'11F. PA1F
M IfPRI [111INFSS. UFSOII SINCFHOLL I1U1_LAFT14 INITPVAL -
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001 'IJUIfS I'f.Y ti5N IrJC11F5 15T WFI IFU $W CLUNG IN MINW L$ I'f RIf1U1 Pf R111nJ PERIVDI MIIQIV
P- _s'C .5 ~ F• !x r. ~ _ _4.;! /sr ,vo ~ ~ 3 I
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SUIT REMIND TESTS -
TFSI Ill1AL UCl'TII IIFVIII IO GROUN[YNATrR INCITES CNANACTI IIOFSOII W1111 TI IICKNFSS, I:OLl10
rE%IUUF. M011 LINO ANU UEV 11. 100EI)RI.:K
4pMP1 n IN14E'i OnSFRVEU ESONIA I LO I IIGI II AT 11 u usFUVFI. IN INLOrS _
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PLAN V ILW ILOC.I 1 mculafun 1,11 1, sot bole h In and ndtabl sod A'Pin 1 In1 e1r nn dw'RIO dm hwat 1 a I Pu.e het ul tollel.<al xas
lodir:ne Ot bar of HIRaIa leel oI auoO. Ption a,.. nxeded inr huildmo ry'pP and'.': 11+.I<L~y' ,S" L j •1 .I...1, le +cale o. J aanen.
Give 11.1 iru.Rat.1111 net a cal at PI tP points. 111,101P S..•%+1/r'A.•>' fir. SYTJJ4,.. i111,101P tlgpe. c..
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I, the undertlpend, erohv rnrtify that IM}u:f Tliu re(roI d on his loan were mad. by mx in ac.NI with tha Proredura arW P.Iho<h
5~ .corded and /L"Ka11un ul Inl hdn are Forted to the beu nl my
spacifinl in me WI ORON Adminislratlile Coalc..Rd that Thirds
k..Irlyl:.nd lieu I.
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AUb A' LLAS'lp lkit Rt; AI)1 4C M(19..1 NA.' Y) m,.YIS 01 LOW Fl"Al..PAUE
M MIA OePrH OF 6XUVATIOP FROM OR16041iL (>KAUE '.III I of Ml RE
MINIMUM Off III OF EXCAVATION FROM OQrGINAL GRAVE `NIU_ nL Oaf LIES
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