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70Q1LHR SANITARY PERMIT APPLICATION COUNTY <br /> M7In accord with ILHR 83.05,Wis.Adm.Code Bu rnpl?L— <br /> ST TE SANITARY PERMIT# <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ST,+TE PLAN I.D.NUIAITER <br /> 81/2 x 11 inches in size. <br /> -See reverse side for instructions for completing this application. PEjTITION <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. F VARIANCE ❑YES ❑ NO <br /> PROPERTY OWNER _ PROPERTY LOCATION <br /> f TL372_ C C= LG(L o✓ Y4vTZ/1/4, S (, T (� N, R II __E(or <br /> PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME <br /> sDt7 G - jj tai — o I- M ) —t---`— <br /> CITY,STATE ZIP CODE PHONE NUMBER 0 CITY NEAREST ROAD.LIKE OR LANDMARK <br /> 611 4 12 VILLAGE: J�GLSa✓ I- �UeOgp <br /> IL TYPE OF BUILDING OR USE SERVED: <br /> Number of Bedrooms if t 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.KReplacement c. ❑Replacement of d.❑ Reconnection of eJ❑ 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 OF SYSTEM: (Check only one in#1 and only one in#2) <br /> 1. a. 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.Zseepage Bed b. ❑Seepage Trench c. ❑Seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. W TER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): <br /> / � i <br /> &/ S6 Q ,?-6 Feet PFivate ❑Joint ❑ Public <br /> VI. TANK CAPACITYin allons Total #of Prefab. Site Fiber- Exper. <br /> INFORMATION New Existing Gallons Tanks Manufacturer's Name Con- Steel I glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank 9 fM <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 r s S' Lure: o Storlm PRSW No.: Business Phone Number: <br /> ,JAI-D . �o_Fria17S (0) __l__ <br /> - ( !7( ;- ) z4�1-�5 0 <br /> Plumber's Address(Street,City,State,Zip Code): Name of Designer: <br /> k i 3 .6c y )v D,9 r Ca,�-rte cJ r - P3� <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tesler(CST)Namer> _ CST# <br /> r C)f-j (� �' �jQ L ��t �,S <br /> CST's ADDRESS(Street,City,State,Zip Code) Phone Number: <br /> 2f d 1 s 2 c1- ,t 5 a <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee Groundwater ate Issui gent Si natur oStamps) <br /> Approved ❑ Owner Given Initial l�p,`r�, S charge/Femme <br /> Adverse Determination 6o.0 �S'cc ��I� �0 � _ <br /> X. COMMENTS/REASONS FOR DISAPPROVAL: <br /> L — <br /> SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber <br /> i <br />