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�] �ILHR SANITARY PERMIT APPLICATION COUNTY <br /> In accord with ILHR 83.05,Wis.Adm. Code ,�` sfi <br /> STATE SANITARY PERMIT# <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBER <br /> 8%x 11 inches in size. <br /> -See reverse side for instructions for completing this application. PETITION <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. r FOR VARIANCE <br /> ❑YES ❑ NO <br /> PROPEL OWNER f JROPEVY L C OS a 3 T U , N, R �l0 f tvW)W <br /> PRO ERTV OWNER S MAILING ADDRESS NUMBER BLOCKNUMBER SUBDIVISIONNAME <br /> OXCITY,STATEZIPCODE PHONE NUMBERCITY NEAF]j=S!ROAD,LAKE OR LANDMARK <br /> J J r ') /J �l 7 (3 c44 VILLAGE : `� �} �/ �/1 �l J <br /> TOWN OF <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 /> 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 <br /> ,OOFFSYSTEM: (Check only one in#1 and only one in#2) <br /> 1. a. *Conventional b. El Alternative C. El Experimental <br /> 2. a. /❑\System- b. ❑ Holding c.L1 Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP <br /> In-Fill Tank <br /> V. ABSORPTION SYSTEM INFORMATION: (Check one) <br /> 1. a. Xseepage Bed b. ❑Seepage Trench C. ❑ Seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 15.SYSTEM ELEVATION 6. WATER SUPPLY: <br /> (Mins"gees per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): <br /> J4 to a 3 Feet Private ❑Joint ❑ Public <br /> CAPACITY <br /> VI. TANK Site <br /> in allons Total #of Manufacturer's Name Pretab. Con- Steel Fiber- Plastic Exper. <br /> INFORMATION New xisting Gallons Tanks cc Concrete strutted glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank 7 8 /C <br /> Lift Pump Tank/Siphon Chamber I Ll I ❑ I U I 1 ❑ 1 Ll 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): lumber's Signatur (No Stamps) MP/MPRSW No.: Business Phone Number: <br /> JoeA f t tS od 1tit �✓ 7 3 3 S' i�/ <br /> Plumber's Address(Street,City,State,Zip Cod Name of signer: <br /> C <br /> Vol. S IL TEST INFORMATION S <br /> Certifie oil Tester(CST)Name CST# <br /> CST's DDRESS(Street,City,State,Zip Code) Phone Number: <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> roved <br /> F-1 Disapproved Sanitary Permit Fee Groundwater ate Issu g Agent Si nature(No Stamps) <br /> lAl A ❑ ¢�/ �t 6 o sSuurcharge Fee r <br /> PP Owner Given Initial <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 />