HomeMy WebLinkAbout002-121-05-2700-SAN-1971-21963 �PPLICATION FOR SA[JYER COUNTY
�9�. SAiJZTARY PERI,IT
_q' Application i:_�� Date � -� �� � �
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� Fee of $Z0,00 rzceived L-l7`7� . �"U
` Date County Clerk
NAppZicattion is hereby made for a Sawyer County Sanitary
Permit for work to be done on tne premises described hereisx.
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Oraner 'Add e§ TeZephone
The o f the Sec. �_ 1'mn.�_ R. �
or '
Lot BZock Sub-divisio ? � --` ^ — � � �
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Work contemplated � � be �erform�
Idumber of Bedrooms 1_ Number of Bathrooms ��
Dishmash.er �/�� Garbage Grinder
Autdr�attic Washer ,�,,_ �
Soil Description
Septic T¢nk Si4e �`)�� '� gal:
Seepage Pit _� �H�z,gJit ''7 Diameter
Seepage Trench" Length � Width Depth
Septic Tank Permit i� �'��j
Percolation Test Form PLii 43 attaehed �
Yes No
Contemplated completion date
Application Approved Permit # �� �
Sanitarian ��rt�w� (� i c r�Ys�-.� �o'- ��` 7 �
`t Oto�ier Agent i'Jo 2 fze Date
Remarks
Final Inspection �+�-n�Q /r J���
Sanitarian �_ y z-7/
O�raer/Agent otified (Date)
Remarks
'�** Send ori.gina2 and three copties �tith.**'� �
fee of $Z0.00 to County CZerk
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Indicate Lot size and shape, Zocation of dwelling 1D1, septic tank
(ST)„ septic fieZd (SF) or seepage pit (SP) and distance of any
portion of septie system from dwelling9 wel2 and property Line .
If property Zies within 50 feet of a Zake, river or a stream so
indicate and show distance therefrom.
If any portion of the contemplated construction �ill Zie withix
25 feet of d�ellin�, r�ell; aeptic tank, septic fieZd or seepage
pit of abbutting owner so indicate.
?he underaigned agrees that all mork performed and equipment
installed shaZl be in accordance �ith the Sanitary Code of Sawyer
County and aZl applicable Zm,�s and regulations of tlie State of
Wiaconatin and recommendations of the Samuer County Sanitarian.
, , �
/" .dfane;�jAgent (Signa ure)
L � �'J
' ` ` itisoon�in D�p�twnt of HN1Lh and Saoial S�rvio�l
` •. Plb, �67 3/70 Dlvltlon o! Henitb
SEPTIC TANK PERMIT APPLICATION
TYPS or US[ BWCY IMC
i. OWNLR OP PROPLRTY
M�� Addr�ss (Sir�at� CSty� Zip Cod�)
" i,l 7 fl (�� i F_ /� � r- , ?' �! �� ,;,���= ��
B. LOCATIQi OF PROPFRI7 itF�AE SYSTElt WILL BE CONSTRUCT6U ALTfiRED OR E)CTE�DSD COUl1N
Ctuak Orie:
CITY VILLU'S L6GAL DESCRIP7I0�7
T SHIP / �-
� �a.� � - �A ,f' �// 7 i _ — �
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C. IS LOCAL PEFUIIT REQUIRED FOR THIS WORK? �,�YES �� NO � PEANIT NUMBCR
D. SEPTIC TANK CAPACITY � Callons NEli INSTALLATION _ PfPL4CQ'�NT � ADDITION
i
MATSRIAIS� pretnb Conorete Poured in Plae� _ Steel � Othe� _�
MRtBFA OF TANKS TO BE INSTAL[�Ds
6. TYPE OP OCCUP�'Y — — —
�Cheok Onet (Ony or 'hro Femi�y Resideroa Co�ercial Induatrial Other
� Spealfy
Humber of Peraona to ba Aoco�odated _.�__ Nunber of Bedrooms �_
.s�
F. APPLIAN�CES, ETC: Food Naet� GrindeT YES �� NO Automatie C1oLhe■ Wesher YF:S�`NO
Distnrasher YiS NO nutomstio Potrto P•�1er YLS�.NO
Othar (Speaify) ���
G. MASTLR pLUMBCR pAYING INSTALLATFdt7
Nrus:"'s � /1 • (N � Addresst ��i� / /��i�l(��^)",T_ Lioenss Minberi
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Sigietw� ot Applioant� � i��� � i � � '� I yp p� � e
Addnase i� � �
H. (To be Comptated by Ieauing Agent) .1'�
Dat� of Applioation �� � � � " 7 � Fee Pald = /
T—
Permii Iawed (da�e) " Permit N er Z/ � 6 3
AgapL (Name) ihf��`I�.Y-� For� ��
� v Tmrn� 1 age� C1 � 6Atiy, etc.
JQ�CS�1.�/y�j� J � (Sp Py)
Note: The'Spplioatio��cennot os aonaiderod for Piiing until all of the above questiona a anawered and the
I fet peid. Age�1ba will Pornard appilcation, Lna fee of j1.Ju for asch sepiio LaNc an ths inlyd oupy
of th� permit (aariary) to th� Division ot Health. Chsoks and woney orda�s shonld b� irde p�,yabl� Lo
ths DSvielon of Hetath.
Do not writ• in epus 6elow - FOR DEP1Ft7TiF.NS USf ONLY
I. DATE RECEIVFTi ACCEPTED BY RETURNm
', (7nitials) (pate) See Corres.)
i FEE RECEIYE� VAISD. No, PERl1I7 N0,
e� or No
REYITNCO BY APPROYW DATi
(Initlale) Yes or No
conrt.e�rs mr� sme
� . �\ ' y I1
SLPTIC 7ANK PERt1I7 NQ.
R Y P 0 R T 0 N S 0 I L P L R C 0 L � T I 0 N T [ S T
� H D S 0 I L B 0 A I N G S
TO
DIYISSOI Ot HEAL?N - PLIHBZN6 S�TFdN
P.O.Boz '309� tlediaoa� liis. S:f701
PursusnL to H 64.20� M1�. �dalclst7'nL1v� Cods
PLRCOLATIOA r � sr
f�et D�pth CMrsota� ot Soil Hours Mat�r Ta�i Tiu� Oro in iiater Level Snohas ut�s
MaEer Imhu Thio�aes in Inoh�s 51no� Hol� Se Bol� D�tuval Sxond to Next to Laat To Fa11
lat fl�tLed Ovslni ln C1LfvEq Lut P�Tlod Ie�et Period psrlod Qu� Inoh
Exempl�
P - 0 36^ To Soil 10• C 26a 25 Y�s or No 30 1 2 3 2 1 2 60
�% F � ; i; � � i F A�;i i
�' '� i / /�.: — //
I , � 7 � I � ' i � . , �
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RECORD DATA FH�d1 MINITIUH OP 3 TYSS HOLfiS
Coeput� iiz� of �baorption s»a in aoaord wiSh H 62,20 Ais. �Aeinistewtivs Cod�.
5 0 I L B 0 A I N G 5 - Miaimum 36�• B�lo� Pro �ed ADso LSon 5 ftp
Boring Total D�pLh Ds Lh to Grouad iint�r Ds th to B�drook
M�ber Inoh�s Obaerv�d isSim�S�d Obeerved SaL1maS�d Chsraat�r oC So11 with Thfeltnese Sn Inoh�a
�sPl� � r
B - 0 72^ 72" U� Blsak To 5011 12� C 18" 5►nd 18�� 6Tave1 24��
� �l� � � �� ; � i �� �� � . �i ; �
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RCCOAD DA71 FROM itINII4Ai N 3 BOflY NOLEi
Pfi OP OCCUPANCYt
AESZ�INCCi N�nbeT of Bsdrooss �L 07'HER� (Speoify) Numbar ot Parsons
D NASTY GRINDHi� Yn _ No v Distarash��� Tos __No �_Automtia tlothaa Apher� Yea _ No _�
FFWENT DISPOSAL 5Y578Mt NEM tJC7LN5I0N �_ ADDITION �� REPL�L'H1EN7' ��
Til� Sii� �� No,L3n.Fest �� Tronoh ifidth � ➢epLh N�ber ot Lines �
S�epag� Bedx Lsngth W3dth DepLh 11� Siss No, Llnes
Se�pag� piit Iaaid� Diaeeter �`7 i Liquid D�ptb�
—T'�
I� Lha undaTelgned, M»by aertity that Lhe peroolation teste r�porEad on Lh1s tors wers made hy me o� under n�y �uper-
vision in a000rd xiih the p�ooedur�s and method spsoifiad in Chepter H 62,20 (13)� Misooaein �d�iqlstroti�� Cod�� and
ttet tM daffi r�ooMed and loeation of tesL holes ars oorraot Lo the beat ot qy knoxledge md beli�P.
N� �� i
�h. i��/��� /�il'.� �; ritu
T+'ry o rrsne
REGISTRARION N0, or HASTER PIUI�ER LICIIiSr N0.
ADDRESS Y � -
� DATfi � SIGNATURC �'�
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