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�ILHR SANITARY PERMIT APPLICATION cou TY <br /> In accord with ILHR 83.05,Wis.Adm. Code r <br /> STATE SANITARY ,JEP # <br /> a <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D. l!) <br /> 8'h x 11 inches in size. <br /> —See reverse side for instructions for completing this application. <br /> PETITION <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES ❑ NO <br /> PROPERTY OWNER PROPERTY LOCATION <br /> Gf4 / T (f,AR 1 E (o W <br /> PROPERTY OWNER'S MAILING ADDRESS )r7hnRd, LOTNUMBER BLOCKNUMBER SUBDIVISION NAME <br /> CITY,STATE I ZIP CODE PHONE NUMBER E3 CITY NEAREST ROAD,LAKE OR LANDMARK <br /> LK✓/{JOE 3�� off! � 7 ❑ VILLAGE: <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. ❑ Reconnection of e.❑ Repair of an <br /> ystem 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. Xconventlonal 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. 6Z�J.See a e Bed b. ❑Seepage Trench c. ❑ Seepage Pit <br /> 2. PERCOLATION RATE 3, ABSORPTION AREA 4. ABSORPTION AREA 15.SYSTEM ELEVATION 6. WATER SUPPLY: <br /> (Minutes er inch): REQUIRED( are Feet): PROPOSED(Sq are Feet): / <br /> lqho7/I /01-,0 Feet Private ❑Joint ❑ Public <br /> VI. TANK CAPACITYin gallons Total #of Prefab. Site Fiber- Exper. <br /> INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Se tic Tank or Holding Tank &A-G. ❑ ❑ ❑ I El ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ I ❑ ❑ <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): :(No to MP/MPRSW No.: Business Phone Number: <br /> kf •PRO t— na[u3072?— 5z0 <br /> Plumber's Address(Street,City,State,Zip Code): k Name of Designer: <br /> Ae r C v& 20 �9/ l,¢n i:) W%- 5Yj 3C <br /> Vlll. SOIL TEST INFORMATION <br /> Certified Soil Tesler(CST)Name CST# 1• <br /> ti.j�n & - PRCr� - - S <br /> CST's ADDRESS(Street,City,State,Zip Code) Phone Number: <br /> X17' 3 5e oc 70 7>,9//� li?s�7 t�Ji sZ530 7,i s'C✓=3 Jb �7 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee Groundwater jDate Iss Agent Sign a(No Stamps) <br /> Approved ❑ Owner Given Initial (�/(Y r7--,i S charge//F��ejje--��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 />