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AILHR SANITARY PERMIT APPLICATION COD U( <br /> In accord with ILHR 83.05,Wis. Adm. Code <br /> STATE ANITARY P MIT A <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than ST TE PLAN I.D.NUMBER <br /> 8Yz x 11 inches in size. <br /> —See reverse side for instructions for completing this application. PETITION <br /> 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE [IYES ❑ NO <br /> PROPERTYOWNER� / PROPERTY LOCATION <br /> LJ YaS[ '/a, S �� T QN, R E (O ) W <br /> PROPERTY OWNER'S MAILING ADDRESS LOuIMBER BLOCK�NUMBER SUED;AISI)N NAME <br /> r � 6� /V <br /> CITY, TAT ZIP CODE PHONE NUMBER CITY NEAREST PC LAKE OR LANDARV <br /> r ❑ VILLAGE : d � YV N ( VNg TOWN 'C/' <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. N 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. ElExperimental <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. See a e 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): PROPOSED(Square Feet): <br /> d Feet Private ❑Joint ❑ Public <br /> VI. TANK CAPACITY jCon- <br /> in as ons_ Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Steel glass Plastic App <br /> Tanks Tanks <br /> Septic Tank or Holdin Tank C [_1 ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ Ll ❑ ❑ <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 ignature: mps) Q _ $MP/MPRSWNo.: Business Phone Number <br /> : <br /> It f�S - <br /> Plumber's Address(Street,Cit ,State,Zip Code): Name of Dyein <br /> —J <br /> VIII. SOIL TEST INFORMATION <br /> Certi 'ed Soil Tester(C T)Name CST# <br /> � h �6 >v <br /> A <br /> CS 's ADD ESS Street,City,State,Zip Code) Phone Number: <br /> Q` yf <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved S nitary Permit Fee Groundwater ate Is ing gent Signatu oStamps) <br /> Approved ❑ Owner Given Initial �/� /`�1 Surcharge Fee <br /> 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 />