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�ILHR SANITARY PERMIT APPLICATION C NTV <br /> In accord with ILHR 83.05,Wis. Adm. Code ol <br /> ST TE SAN ITARY PERM IT# <br /> mmmons7 <br /> —Attach complete plans(to the county copy only)for the system, on paper not less than ST kTE PLAN I.D-INUMBER <br /> 8'FA x 11 inches in size. <br /> —See reverse side for instructions for completing this application. <br /> PE rITION <br /> 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES ❑ NO <br /> PROPERTY OWNER !J PROPERTY LOCATION <br /> TU rt4� to � N41 '/< S Y4, S /S Tyo, N, R 6 € (orW <br /> PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISI N NAME <br /> )q 1 6 6 v Y Al A- k <br /> CITY, TAT N ZIP CODE PHONE NUMBER CITY / NEAREST I OAD,LAKEO L.gNDMARK <br /> affmft L-0S 0 VILLAGE :5b TOWN OFQ 4�L d r J'f Al- kQ <br /> 11. TYPE OF BUILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family OR ❑ Public(Specify): <br /> Ill. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) <br /> 1. a. N 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 AgreeME nt to County Copy. <br /> IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2) <br /> 1. a. gConventional 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. 5d seepage Bed b. ❑Seepage Trench C. ❑ Seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. W TER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): 77 0 t S­ IS <br /> IS 91T !.3 Feet X P ivate ❑Joint ❑ Public <br /> CAPACITY <br /> VI. TANK in allons Total #of Prefab. Site Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Ste I glass Plastic App <br /> Tanks Tanks structed <br /> Septic Tank or Holdin Tank /1dd ( �� ❑ <br /> Litt Pum 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): Plumber's Signature:(No Stamps) MP/MPRSW No.: Bu iness Phone/Nu�mbetr, <br /> Plumber's Address(Street,City,State,Zip Code): Name of Designer: <br /> ,A. 6 a � J <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name CST# 76 <br /> Phone a <br /> CST's ADDRESS Street,City, tate, ip Code) Phone Numb r: <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee Grocu„awaateree ate Issui gent Si nat No Stamps) <br /> Approved ❑ Owner Given Initial � �1 g <br /> Adverse Determination R U l� d r <br /> X. COMMENTS/REASONS FOR DISAPPROVAL: <br /> L <br /> SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber <br />