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ILHR SANITARY PERMIT APPLICATION COUNTY <br /> _ In accord with ILHR 83.05,Wis. Adm. Code <br /> STATE SANITARYPERMIT <br /> a 3887 <br /> -Attach complete plans(to the county copy only)for the system, on paper not less than STATE PLAN I.D.NUMBER <br /> 8'h x 11 inches in size. <br /> -See reverse side for instructions for completing this application. PETITION <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES ❑ NO <br /> PROP RTYOWNER PROPERTY LOCATION <br /> f <br /> PC 1/4 $E '/a, S � T qO N, R E (or W <br /> PROPERT OWNER'SMAI G ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME <br /> CITY,STATE ZIP CODEPHONE NUMBER CITY NEAR ST ROAD,LAKE Og LANDMARK <br /> � L I OWN VILLAGE :Tv C SQ N �• p jf / <br /> If. TYPE OF BUILDING OR USE SERVED: •t n. 6 <br /> Number of Bedrooms if 1 or 2 Family OR ❑ Public(Specify): <br /> III. PURPOSE OF APPLICATION: (Check only ane 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 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.El Pit Privy d. ❑ Vault Privy e. ❑ Mound I. ❑ IGP <br /> In-Fill Tank <br /> V. ABSORPTION SYSTEM INFORMATION: (Check one) <br /> 1. a. XT 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): PROP/OSED(Square Feet): t� <br /> d `Y a / S.S Feet ®Private ❑Joint ❑ Public <br /> CAPACITY <br /> VI. TANK #of Prefab. Site Fiber- Exper. <br /> in allons Total Manufacturer's Name Con- Steel Plastic <br /> INFORMATION New xisting Gallons Tanks Concrete glass App. <br /> Tanks Tanks strutted <br /> Se tic Tankor Holdin Tank ? SO f tt!'� ❑ ❑ <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): PIu is Siignature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> R0 d <r/c k 0 10ih S Q , ©� 0 T- , 6- /J <br /> Plumber's ddrre/essss(Street,City,State,Zip Code): Name of Designer: <br /> yr , <br /> VIII. SOIL TEST INFORMATION AV <br /> Certified Soil Tester(CST)Name CST# <br /> CST's Aq(DRESS(Street,City,Slate,Zip Code) Phone Number: <br /> 7-D 7-:;f, Wi Cv <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved I Sanitary Permit Fee Groundwaterate ss g ent Sign ur oStamps) <br /> Approved E] Owner Given Initial O q0 S ch Fee �� <br /> Adverse Determination • • co <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 />