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fl �ILHR SANITARY PERMIT APPLICATION G TY <br /> In accord with ILHR 83.05,Wis. Adm. Code <br /> ST TE SANITARY P RMIT# <br /> if- <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ST kTE PLAN I.D.NUMBER <br /> 8'%x 11 inches in size. <br /> —See reverse side for instructions for completing this application. PE rITION <br /> 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FC R VARIANCE ❑YES ❑ NO <br /> PROPERTY OWNER PROPERTY LOCATION <br /> W1 if a " C4 r fi r- A)EF% 5 '/<, S T 3 , N, R �/ It(or)W <br /> POE S 1d 4 /LIONGADD ESS LOT;U'MBER BLOCK/�MBER SUBDIVISION NAME <br /> IV <br /> CITY, TATE h ZIP COdD/rE PHONE NUMBER CITY!At NEARESTOAQ,I,AKEQR LANDMARK <br /> C I-- F¢ �I O 3 177-3/7 rV TOWN VILLAGE : R4 S CO ��4/ �1TL <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. New b. ❑ Replacement c. ❑ Replacement of d.ElReconnection of e ❑ Repair of an <br /> Z 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 Agreement to County Copy. <br /> IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2) <br /> 1. a. K 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. PP Seepage Bed b. ❑ seepage Trench c. ❑ seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): i PROPOSED((Square Feet): <br /> S_ 6 /4r— 6 9,D Ftp Feet ® rivate ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in allons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. <br /> INFORMATION New xisting Gallons Tanks Concrete strutted glass App. <br /> FE <br /> Tanks Tanks <br /> Septic Tank or Holdin Tank /.1.0 O ) LJ �- ❑ <br /> Litt Pum 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): Plumber's Signature:(No Stamps) MP/MPRSW No.: BL siness Phone Number: <br /> rf' O� eS > /T—)f66- WS-7 <br /> Plumber'sPPddress(Street,City,State,Zip Code): Namyy,I Designer: <br /> Web 7T w ' .rY � 3 464 <br /> Vlll. SOIL TEST INFORMATION <br /> Ce Tied oil Tester(CST)Name CST# <br /> Q `2 I r C P2 <br /> CST's <br /> �ApDDRESS treet,City,Stale,Zi Code) �p Phone Numter: <br /> l 'L S k-o-f . -3 G / ft(p /S <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Say(-tary Permit Fee Guroo�undwater, ate is su' g gent Si nat No Stamps) <br /> Approved ❑ Owner Given Initial yf �D ob $3S./M <br /> Adverse Determination <br /> kkk111 bU uv �D U(J a 2i <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,Plumbe <br />