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�ILHR SANITARY PERMIT APPLICATION COUNTY <br /> In accord with ILHR 83.05,Wis.Adm.Code Burn <br /> ST' TE SANITARY PERMIT# <br /> a <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NW R <br /> 8'%x 11 inches in size. <br /> -See reverse side for instructions for completing this application. PEjrITION <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. F R VARIANCE ❑YES ❑ NO <br /> PROPERTY OWNER _ PROPERTY LOCATION <br /> P�TC/2_ C ' E7 LC(LSp� 0V %b31Z/%, S is, T d N, R 11S; rYC <br /> PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME <br /> Soo C r ti o --�— <br /> CITY,STATE ZIP CODE SPP/HONE NUMBER CITY NEAREST ROAD,LAKE OR LANDMARK <br /> (012 Q6(�� () ❑ VILLAGE : ')�Ct GSpq/ Lam, �K0�� <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.KReplacement c. ❑ Replacement of d.❑ Reconnection of e.11❑ 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#t and only one in#2) <br /> 1. a. Conventional b. ❑Alternative C. ❑ Experimental <br /> 2. a. ❑System- b. ❑ Holding c.1:1 Pit Privy d. ❑ Vault Privy e. ❑ Mound f. IGP <br /> In-Fill Tank <br /> V. ABSORPTION SYSTEM INFORMATION: (Check one) <br /> 1. a.Ivseepage 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): PROPOS/ED(Square Feet): \ <br /> 6�l S P Q �-6Feet Pfivate []Joint ❑ Public <br /> VI. TANK CAPAConsITY #of Prefab. Site Fiber- Exper. <br /> in a xisti Total Manufacturer's Name Con- Steel Plastic <br /> INFORMATION New xistin Gallons Tanks Concrete strutted glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank 4 — -r-, Vvi _C <br /> Lift Pum Tank/Siphon Chamber El ❑ ❑ ❑ ❑ <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): q Plu is S' tures No StamM. MP/MPRSW^�No.: Buiness Phone Number: <br /> Plumber's Address(Street,City,State,Zip Code): Name of Designer: <br /> XT .3 65.)r 1 v <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Named _ CST# <br /> O N /-�C) . 7� L`i t`t CJ-S <br /> CST's ADDRESS(Street,City,State,Zip Code) Phone Number <br /> A <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee Groundwater ate Issui gent Si natur 0Stamps) <br /> Approved ❑ Owner Given Initial �q)[�) S charge,FFee� <br /> Adverse Determination 60'"" �S'vv -/,/ �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 />