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��LHR SANITARY PERMIT APPLICATION G TY (� <br /> In accord with ILHR 83.05,Wis.Adm. Code <br /> bL— <br /> S TE SANITARYP RMIT-#�-7 <br /> 3J / <br /> -Attach complete plans (to the county copy only)for the system,on paper not less than ST ATE PLAN I.D.NUMBER <br /> 8'%x 11 inches in size. <br /> -See reverse side for instructions for completing this application. PE TITION <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. FC R VARIANCE ❑VES ❑ NO <br /> PRO RTY OW�N�R PROPERTY LOCATION <br /> Q /1�/�CiC/)5 5ith',(/ A., Sip T /, N, R ,(5' E (or <br /> PROP TV OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME <br /> '01611""1 17 <br /> C/�nT.3(XJ/ Wr ZIP nU PHJI,SNU NDMARK <br /> VIL AGE TOWN OR <br /> : GU7f/'Clf/ NEAREST <br /> OA�/Z7CS/J D,LAKE OR LAKE///P� <br /> 11. TYPE OF BUILDING OR USE SERVED: L <br /> Number of Bedrooms if 1 or 2 Family a 6eu16IQv-A5 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 /> 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. Xconventional b. ❑Alternative C. ❑ Experimental <br /> 2. a. ❑System- b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. El 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''(S//quare Feet): PROPOSED Squ re Feet): <br /> 7/0 9'�•� Feet p6FIrivate El Joint ❑ Public <br /> VI. TANK CAPACITYn allons Total #of Prefab. Site Fiber- Exper. <br /> INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Ste I glass Plastic App <br /> Tanks Tanks <br /> Ty strutted <br /> Septic Tank or HoldingTank ' 6 /„G I El El Li 1 11 <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): Plumber's ignature:( Sta ps) MP/MPRSW No.: BL siness Phone Number: <br /> k/ �e ,Xu s/io/rn 3fo/ 7/-5 �Glo -7aPlp <br /> Plumber's Address(Street,City,State,Zip Code): Name of Designer:�J ^ <br /> o?�s u/ebs�u, u/I �z/�9.3 bTlade .cc�YJI7 �M <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name CST# <br /> U/ade ,&161Ao/m &3 <br /> CST's ADDRESS(Street,City State,Zip Code) Phone Num r: <br /> X 4P� u/e�>< kelI Sidi 3 s PGG -. ?67l <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved I Sanitary Permit Fee Groundwater ate I uin Agent Si natu oStamps) <br /> Approved ❑ Owner Given Initial (X3/,1 I[1Xr.; S rcharge/Fee <br /> 1 /y <br /> Adverse Determination al. A— O�j'�-v G!/ <br /> X. COMMENTS/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)IF 03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber <br />