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�ILHF3 SANITARY PERMIT APPLICATION °O Y <br /> In accord with ILHR 83.05,Wis.Adm.Code ST TESANITARY P RMIT# <br /> —Attach complete plans(to the county copy only)for the system, on paper not less than ST TEAN I.D.N BER <br /> 8'%x 11 inches in size. 1 <br /> �P/L310 <br /> —See reverse side for instructions for completing this application. PE ITION <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. Fo VARIANCE ❑YES X NO <br /> PRO ERTY OWNER PROPERTY LOCATION <br /> Ory �W (o Orr/�/-S SW '/a,(-E '/a, S ayT `/O, N, R E (or) W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISIC N NAME <br /> ti at g ex /0 � V/f GrU c 0, r <br /> CITY,STATE _GYv�()?,{'/ ZIP CODE PHONE NUMBER O0 CITY VILLAGE: <br /> NEAREST Aq,LAKE OR LANDMARK <br /> WCS S 8 Sco Co c( <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. Q 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 it to County Copy. <br /> IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2) <br /> 1. a. ❑Conventional b. Y 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. ❑ See a e Bed b. ❑Seepage Trench C. ❑ See a e 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 /> Feet ❑P ivate ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in all ns Total #ofPrefab. Fiber- Exper. <br /> INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Stee glass Plastic App <br /> Tanks Tanks strutted <br /> Se tic Tank or HoldingTank -ra 1 L..t'C- 9 El ❑ <br /> Lift Pump Tank/Siphon Chamber -Z 51 ❑ ❑ ❑ ❑ <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.: Business Phone Number: <br /> O rtG ILS T r 03 0 /S W -YID 7 <br /> lumber'sAddress(Street,CitV,State,Zip Code): Name Designer: <br /> 6 r 1-J-' -T . S� F <br /> VIII. SOIL TEST INFORMATION <br /> Cer� dJSPpil Tester Name t. CST# /S <br /> U(ipr-[c{\ f1 71 (SLS 7'J <br /> CST's ADDRESS(Street,City,State,Zip Code) Phone Numb r: <br /> r <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved I Sanitary Permit Fee Groundwater ate Iss g gent Si n e(No Stamps) <br /> Approved ❑ Owner Given Initial } �Q� S rcharga,Fee _f� <br /> Adverse Determination •i.1V <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 />