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ILHR SANITARY PERMIT APPLICATION GO NTY <br /> In accord with ILHR 83.05,Wis.Adm. Code I-rle_ -+ <br /> ST TE SANITARY P5RMIT# <br /> ( BS 1-3 <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than ST TE PLAN I.D.NTMBER <br /> 8'%x 11 inches in size. <br /> —See reverse side for instructions for completing this application. PE (TION <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FO VARIANCE ❑YES ❑ NO <br /> PROPERTY OWNER PROPERTY LOCATION <br /> -rii s Ta m l"f I n` c. CL/ <br /> Ys$c '/4, S 3�' TS� , N, R I r <br /> PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISI NAME <br /> lZox 3-vi 1 CS'wt4 4 Vol Il P3CT <br /> CITY,STATE ZIP CODE HONENUMBER CITY NEARESL ,LAKE OR LANDMARK <br /> sY87 W VILLAGE Nn e �S v hd a R0414 <br /> Si I eh W , ✓ <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#2,3 or 4, if applicable) <br /> 1. a. X 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. TYPEOFSYSTEM: (Check only one in#1 and only one in#2) <br /> 1. a. Ipl Conventional b. ❑Alternative C. ❑ Experimental <br /> 2. a. ❑System- b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. 11 IGP <br /> In-Fill Tank <br /> V. ABSORPTION SYSTEM INFORMATION: (Check one) <br /> 1. a. X Seepage Bed b. ❑seepage Trench c. ❑ Seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WP TER SUPPLY: <br /> (Minutes per inch): r�;REQUIRED(Square Feet): PROPOSED(Square Feet): ro1 <br /> 3— 3 — &/� G= ro W'S-9 Feel XP 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- Stee glass Plastic App <br /> Tanks I Tanks I strutted <br /> Septic Tank or Holding Tank Y000 IFSPI &),(reli X I I I ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ <br /> VII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility f installation of the private sewage system shown on the attached plans. <br /> Plumber's Name(Print): PI tuber' Signature (No tamps) MP/MPRSW No.: Bu mass Phone Number: <br /> et5 koel- r �� MP S7ey <br /> PI ber's Address(Street,Citytate,Zip Code): Name of Designer: <br /> VIII. SOIL TEST INFORMATION <br /> Ceified Soil Tester(PST) me CST# -� <br /> 2e/I s- -robe/ <br /> CST's ADDRESS(Street,City,St te,Zip Code) Phone Number <br /> (,)Pts- C �Jr S 5��13 7/-r SV I?- D1 To <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sa itary Permit Fee Groundwater ate Issuin gent Si nature(No Stamps) <br /> Approved ❑ Owner Given Initial (��j,\ �,(�j�) S chhaarrg-e�Fee <br /> Adverse Determination <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 />