Laserfiche WebLink
�ILHR SANITARY PERMIT APPLICATION C TY! <br /> In accord with ILHR 83.05,Wis.Adm. Code STATE SANITARY YRV # <br /> ommmm H4�j' r L4 III <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D. UMBER <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. FOR VARIANCE ❑YES [ANO <br /> PROPERTY OW.Nf—ER ENG <br /> ATION <br /> ROI eF-I �4 't. v w Y4, S / 3 T4/o, N, R IS" E (or W <br /> PROPERTY OWNER'S MAILING ADDRESS BLOCK NUMBER SUBDIVISION NAME <br /> ;L-:S Bvoo I 0f. Nq -et fT-c � <br /> CITY,STATE ZIP CODE PHONE NUMBER NEAREST R AD,LAKE OR NDMA K <br /> )Ivv �S �'1 h• S��j o 7. Se v TJ <br /> II. TYPE OF BUILDING OR USE SERVED: <br /> Number of Bedrooms it 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. 0i Replacement c. ❑ Replacement of d.❑ Reconnection of e.❑ Repair of an <br /> System System Septic Tank Only an Existing System I 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. M Conventional b. ❑ Alternative C. ❑ Experimental <br /> 2. a. ❑System- b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound I. ❑ IGP <br /> In-Fill Tank <br /> V. ABSORPTION SYSTEM INFORMATION: (Check one) <br /> 1. a. V seepage Bed b. ❑ Seepage Trench c. ❑ Seepage Pit <br /> 2. PERCOLATION RATE 13. ABSORPTION AREA 4. ABSORPTION AREA 15.SYSTEM ELEVATION 6. WATER SUPPLY: <br /> (Mi nttl-fomes per inch): REQU4IfiE. D(Square Feet): PROPOSED(Square Feet): q <br /> J l4Q 7 3 6 / Feet 5OPrivate ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in al Ions Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septi Tank or Holding Tank Z9,1) P-10 I ® 11 ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber t I 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): <br /> Plumber's�Signature:/(No Stamps) MP/MPRSW No.: Business Phone Number <br /> / : <br /> r[ Q 4t n�c 4 q' �i.13 fixC6 0 S- ? ?!S V& <br /> Plumber's Address(Street,City,State,Zip Code): Name of(Designer: <br /> 1 <br /> `N & r- %_ `L- V *py-k --t, <br /> VIII. SOIL TEST INFORMATION <br /> Certified oil Tester(CST Name CST# ' <br /> Q t ncc K . (%'p <br /> rK S SLl <br /> CST's ADDRESS(Street,City,State,Zip`Code) Phone Number: <br /> UQ r6 Vii-- wt- ( fC6�tlJ <br /> COUNTY/DEPARTMENT USE ONLY <br /> Disapproved S�aggitaryy Permit Fee Groundwater at Is in gentIr- <br /> F-1 (No Stamps) <br /> ,H-, [y� rcharLge F e �/ /'I <br /> pproved ❑ Owner Given Initial �`HN'� Uu�° / 'bjJ� IG <br /> Adverse Determination <br /> fy <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 />