Laserfiche WebLink
ILHR SANITARY PERMIT APPLICATION C UNTYTff �/ <br /> In accord with ILHR 83.05,Wis.Adm. Code (y rAt°4 <br /> S1 ATESNITARYP MIT <br /> f � 5 <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than S TE PLAN I.D.NUMBER <br /> 8'%x 11 inches in size. <br /> —See reverse side for instructions for completing this application. PE TITION <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES ❑ NO <br /> PROPERTY OWNER PROPERTY LOCATION <br /> Y Yt l- � e 6 '/as U/'/a, S�q T J/O, N, R f{o W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISI N NAME <br /> ISIIo a� e fir. �- <br /> CITY,STATE ZIP CODE PHONE NUMBER CITY \ NEAREST O AK / R LANDMARK <br /> I11P(S s _q3s TOWNVILLAGE:JQ�I�sO I a <br /> II. TYPE OF BUILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family 3 OR ❑ Public(Specify): <br /> III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) <br /> 1. a. V 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 Agreem nt to County Copy. <br /> IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2) <br /> 1. a. Wonventional b. ❑Alternative c. ❑ Experimental <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. ® seepage Bed b. ❑Seepage Trench c. ❑ Seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. W ATER SUPPLY: <br /> (Minutesr inch): REQUIRED(Square Feet): PROPOSE D Square Feet): [� 7 <br /> Z- 3— p lois (C7� " 33 Feet ®Rrivate ❑Joint ❑ Public <br /> VI. TANK CAPACITYin allons Total Site P <br /> #of Manufacturer's Name Prefab. Con- Ste Fiber- plastic Expe <br /> New xistin Gallons Tanks Concrete strutted glass App. <br /> INFORMATION <br /> Tanks I Tanks <br /> Septic Tank or Holdino Tank X 16001W l r-SP C.o lC% <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ El ❑ <br /> VII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility fo installation of the private sewage system shown on the attached plans. <br /> Plumber's Name(Print): PItier's ignatur :IN Stamps) MP/MPRSW No.: Business Phone Number: <br /> (S r , ( /V P �7 t S �Yo6—xklr <br /> Plumber's Address(Street, it State,Zip Code): Name of Designe <br /> k.v e 4 I S (S Lw <br /> VIII. SOIL TEST INFORMATION <br /> Certii d Soil Tester�T)Nammee ( CST# <br /> as <br /> MbQ <br /> CSI's ApDRESS(Street,City,Stat Zip Code) Phone Num er: <br /> -t- Z - �%-W i W i S S"( / 3 9-a 990 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> \ryj-� ❑ Disapproved Sanitary Permit Fee Groundwater ate Is sui ntS gnature amps) <br /> 1Ly Approved ❑ Owner Given Initial q� Q0 W urc�arge Femme O .y� <br /> Adverse Determination J! ��V w vh IF <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,Plumbe <br />