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�ILHR SANITARY PERMIT APPLICATION TY <br /> In accord with ILHR 83.05,Wis.Adm. Code r <br /> S ATESANITARYRMIT# <br /> P <br /> 13 <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than SI ATE PLAN I.D.NUMBER <br /> 8'h x 11 inches in size. <br /> —See reverse side for instructions for completing this application. PETITION <br /> 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. F R VARIANCE ❑YES ❑ NO <br /> PROPERTY OWNER PROPERTY LOCATION <br /> Wti , F CowCseN w'/4 NE Y4,S 3a TyO, N, R E (or) w <br /> PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISI N//NAME ` <br /> 1116 K6 L1urot4 Af-lv `t.. Cl N �r IG,W �.�7C`e. CST¢ <br /> rj <br /> C(LJTY,STATE ZIP CODE PHONE NUMBER CITY N RST OAD,LAKE OR LANDMARK <br /> '1 lJ'P r' �4� 03.1. 0 VILLAGE : OQ/�L4w� /e U L.IL r1 `L. <br /> II. TYPE OF BUILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family a' 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 ❑ 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. ❑ 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. M Seepage Bed b. ❑ seepage Trench c. ❑ Seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 14. ABSORPTION AREA 5.SYSTEM ELEVATION 6. W NTER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED <br /> 1(Square Feet): p 7 <br /> 7, 41 3 .1 Feet ® rivate ❑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 strutted <br /> Septic Tank or Holdro Tank x 1 7S0 1 1 1 y—n'f C_ I ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber )eI %S b 'r M C ❑ ❑ ❑ ❑ ❑ <br /> VII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plan . <br /> Plumber's Name(Print): Plumber's Signature:(No Stamps) MP/MPRSW No.: Biisiness Phone Number: <br /> /Pedterytk 90 ffinr 4930sQ lis P is 7 <br /> Plum 's ddress(Street,City,State,ZW Code): r Name of[)esigner: <br /> VIII. SOIL TEST INFORMATION <br /> Ce 'ed So'I Tester(CST)Name CST# <br /> 6 —rie, k Q �( v1 C � 7 <br /> CST's ADDRESS(Street,City,State,Zip ode) Phone Number: <br /> w-e6 3ITt— u,( IT, 7�s �6 ells <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved T-0 <br /> �anrf'1-larry/Permit Fee Groundwater ate Issum gent S gnature(No Stamps) <br /> VApprovadF_1 Owner Given Initial yl -0 X71 Sc � e Fee <br /> Adverse Determination ��--FFi/ V <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 />