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�ILHR SANITARY PERMIT APPLICATION Xh <br /> ISTTES4A <br /> Y <br /> In accord with ILHR 83.05,Wis. Adm. Code <br /> N ITA Y ERMITI O <br /> -Attach complete plans(to the county copy only)for the system, on paper not less than ST TE PLAN I.D.NUMBER <br /> 8'/x x 11 inches in size. <br /> -See reverse side for instructions for completing this application. PE rITION <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. I FC R VARIANCE ❑YES ❑ NO <br /> PROPERTY OWNER PROPERTY LOCATION <br /> �C�t3Q�S /QCQ/ 5E'/a SU�'/a, S 7 T 00, N, R/ E (or& <br /> PROPERTY OWNER'S MAILING ADDRESS LOT 7BER BLOCK NUMBER SUBDIVISION NAME <br /> CITY,STAT E/ ZIP CODE�7 PH/O-NE�jNUMBE CITY /y, L �/ NEAREST OAD,LAKE OR LANDMARK <br /> /l1[:,YJ � Q3/ rJ�/ol �7Y� VILLAGE : Com.WO.-7C/ e// It/ 4 j/C/- <br /> 11. TYPE OF BUILDING OR USE SERVED: �,,/ <br /> Number of Bedrooms if 1 or 2 Family +6// �0077`5 OR ❑ Public(Specify): <br /> III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2.3 or 4,if applicable) <br /> 1. a. O 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 Agreem nt to County Copy. <br /> IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2) <br /> 1. a. W 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. See a e 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): PROPOSEDuare Feet): n�7 <br /> .3 //r� / (S 9 `5_ rpf Feet % rivate ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in allons Total #of Prefab. 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 HoldingTank 7S� m ❑ <br /> Lift Pum Tank/Si hon 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: o St mps) MP/MPRSW No.: B siness Phone Number: <br /> u/ade &{..3126/m �a� 33G/ 725' p(o(o- qa8� <br /> Plumber's Address(Street,City,State,Zip Code): I Name of Designer: <br /> ,?&050 %rarf Ave. J. 141T WOL-le ,C�f�hU <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name CST# <br /> xl/ ylG /�/fa�7o/rr7 83 <br /> CST's ADDRESS(Street,City,Slate,Zip Code) Phone Num er: <br /> IX. COUNTY/DEPARTMENT USE ONLY 111 <br /> Disapproved Sanitary Permit Fee Groundwater ale Is in Agent Si ature(No Stamps) <br /> Approved ❑ Owner Given Initial SQurcharge Fee <br /> Adverse Determination ""�' s <br /> X. COMMENTS/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Pb-67)(R.03/86) DISTRIBUTION: Original to County.One Copy To:Bureau of Plumbing,Owner,Plumbe <br />