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�ILHR SANITARY PERMIT APPLICATION CD. TY <br /> In accord with ILHR 83.05,Wis.Adm. Code <br /> STATE SANITARY P MIT# <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. PETI= <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. FOR VARIANCE OYES ❑ No <br /> PROPERTY OWNER PROPERTY LOCATION <br /> orris o si Se /4 S&'/a, S ay T 0N, R &V(or) W <br /> PROPERTY OWNER'S/AILING ADDRESS LOT NUMB R BLOCK NUMBER SUBDIVISIONAME <br /> CITY,STATEJ �.1 ZIP CODE PHONE NUMBER CITY rV NEARESTROAD,ROAD,LAKE OR LANDMARK <br /> C d iprs 61.4,1 ' ,T96J"S 151'TOWN OR❑ VILLAGE : rt r 2 w <br /> 11. 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. IN 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. DS 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. TFSee a e Bed b. ❑Seepage Trench c. ❑ Seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): <br /> 'F'l s— �{ O �? i v Feet XPrivate ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> In a11 ns Total #of Manufacturer's Name Prefab. Con- Steel Fiber- plastic Exper. <br /> INFORMATION New xisting Gallons Tanks Concrete glass App. <br /> Tanks Tanks structed <br /> Septic Tank or Holdinq Tank 000 C ❑ El ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ <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): Plumign lure:(No S ps) MP/MPRSW No.: Business Phone Number: <br /> tic O S� <br /> Plumber' ddr ss(Street,City,S te,Zip Code): Name of Designer: <br /> Vlll. SOIL TEST INFORMATION <br /> C"ed S l Tester(CSTJ Name)f n / CST# / <br /> /�,� r <br /> CST's ADDRESS(Street,City,Suite,Zip Code) Phone Number: <br /> 'Nia X15 6 S <br /> I OUY/ MNT USE Y <br /> ❑ Disapproved Sanitary Permit Fee Groundwater ate Issu Agent Si ture(No Stamps) <br /> Approved ❑ owner Given Initial //��/(''�� Surcharge pFee s <br /> Adverse Determination ��`�/v 0 O <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 />