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=13ILDISANITARY PERMIT APPLICATION cou TY l <br /> HHR In accord with ILHR 83.05,Wis. Adm. Code ( 1C Lid <br /> ST TESANITAR PERMIT# <br /> –Attach complete plans(to the county copy only)for the system,on paper not less than SI.D.NUMBER <br /> 8%x 11 inches in size. TATE PLAN <br /> –See reverse side for instructions for completing this application. <br /> I. APPLICANT INFORMATION–PLEASE PRINT ALL INFORMATION. PETITION <br /> PROPERTY OWNER PROPERTY LOCATION FOR VARIANCE ❑YES ❑ NO <br /> (7�e 0 TP a YIE % Z '%, S _V T Z/, N, R / db(or) W <br /> PROPERTY OWNER'S M ILING ADDRESS LOT:UIMBER BLOCK NUXMBER SUBDIVI$IQN NAME <br /> CITY,STA E/ ` ZIP CODE PHONENUMBER CITY N"'A! NEARESTROAD AKE OR LA DMARK <br /> N ❑ VILLAGE : ^s, � <br /> II. TYPE OF UILDING OR USE SERVED: V' <br /> Number of Bedrooms if 1 or 2 Family OR ❑ Public(Specify): <br /> III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) <br /> 1. a. ❑ New b. [�;Replacement c. ❑ Replacement of d.❑ Reconnection of e.❑ Repair of an <br /> System System Septic Tank Only an Existing System Existing System <br /> 2. ❑ A Sanitary Permit was previously issued. Permit# Date Issued <br /> 3. ❑ An Existing System has been inspected and soil conditions meet minimum requirements. <br /> 4. ❑ The System is shared by more than one owner/building. Attach Common Ownership Agreement to County Copy. <br /> IV. TYPE <br /> IIOOF'';;SYSTEM: (Check only one in#1 and only one in#2) <br /> Ip <br /> 1. a. conventional b. ❑Alternative C. ❑ Experimental <br /> 2. a. ❑System- b. ❑ Holding C.El Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP <br /> In-Fill Tank <br /> V. ABSORPTION SYSTEM INFORMATION: (Check one) <br /> 1. a. See a e Bed b. ❑See a e Trench c. ❑ seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA TSYSTEM—EL—EVATIltON 6. WATER SUPPLY: <br /> (Minu per inch): REQUIRED(quare Feet): PROPOSE9`1 07D' (Square Feet) 9 �gCAPACIT1 FeeK3'Private ❑Joint ❑ Public <br /> VI. TANK in allons Total #of Site <br /> INFORMATION Manufacturer's Name Prefab. Con- Steel Fiber- plastic Exper. <br /> New xisting Gallons Tanks Concrete glass App. <br /> Tanks Tanks structed <br /> Septic Tank or HoldingTank 7$Yl <br /> Lift 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' igna re:(No St ps) MP/MPRSW No.: Business Phone Number: <br /> nFlu-ber' Address(Street,CI y,State,Zip Code): Name of Designer: <br /> «L� S <br /> VIII. SOIL TEST INFORMATION <br /> Car d So" Test`r(CST Name CST# <br /> c hs �� <br /> CST'sAD (Street,City,State, p de) Phone Numbertu : <br /> S Q fee is <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sani�a,+�y Permit Fee �Surcharge <br /> r ate Issui gent Signat a(No to ps) <br /> Approved ❑ Owner Given Initial �j ® �a �� �� <br /> Adverse Determination `r • <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 />