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�ILHR SANITARY PERMIT APPLICATION C NTY <br /> r <br /> In accord with ILHR 83.05,Wis. Adm. Code ( <br /> ST kTE SANITARY PERMIT# <br /> f <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than Sr kTE PLAN I.D.N1JMBER <br /> 8'%x 11 inches in size. <br /> —See reverse side for instructions for completing this application. PE ITION <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FO 9 VARIANCE ❑YES ❑ NO <br /> PROPERTY OWNER PROPERTY LOCATION <br /> oft O S TyU, N, R {ct (or)W <br /> PROPERTY OWN R'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NnAM`E�I <br /> kr CS <br /> -f N -fV. 3 P' 3) <br /> CITU,STATE / ZIP CODE PHONE NUMBER CITY /�- / NEAREST OAD,LAKE OR LANDMARK <br /> C j C6 W .S ( 1 AGE <br /> jj VILL : b.Q 7 1 O!�Q/ .0 0 F <br /> �E <br /> 11. 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. [4 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 Agreem nt to County Copy. <br /> IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2) <br /> 1. a. 54Conventional 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. IN Seepage Bed b. ❑ Seepage Trench c. ❑ Seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4, ABSORPTION AREA 5.SYSTEM ELEVATION 6. WA TER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): / r� <br /> `41 Y O (o' 3 Feet XP ivate ❑Joint ❑ Public <br /> CAPACITY <br /> VI. TANK n allons Total Of <br /> Prefab. Site Fiber- Exper. <br /> INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Ste I glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank7SU t <br /> Lift Pump 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): Plu er's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> I0 f te � o h RT 4c3 d /T- $ <br /> Plumber's Address(Street,City,State,Zip Code): Name of Designer: r <br /> t ! MZ <br /> _ <br /> VIII. SOIL TEST INFORMATION <br /> Ce ified oil Tester(CST)Na e / CST# <br /> - 36 (7 <br /> CST's ADDRESS(Street,City,State,Zip Code) Phone Number <br /> w� 6 1' c-- - . ."s Wibf CT <br /> I COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee Groundwater ate Iss g ent Si nature(No t s) <br /> /�^� Surcharge Fee <br /> Approved ❑ Owner Given Initial �.V L/ / �p <br /> Adverse Determination (� O' <br /> X. COMMENTS/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.03/86) PiSTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber <br />