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O QiLHR SANITARY PERMIT APPLICATION GD NTY U Y � // // <br /> In accord with ILHR 83.05,Wis.Adm. Code le(IL <br /> .�,�� ST TE SANITARY P MIT# <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than ST LTE PLAN I.D.NUMBER <br /> 8%x 11 inches in size. <br /> —See reverse side for instructions for completing this application. PE ITION <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FO I VARIANCE ❑YES ❑ NO <br /> PROPERTY OWNER I,PROPERTYLOCATION <br /> cI PFSo,� /1/E '% W%, S T3&, N, R <br /> PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME <br /> C`'. <br /> CITY,STATE ZIP CODE PHONE NUMBER CITY NEAREST OA LAKE OR LANDMARK <br /> 5 �rel� tS -Sq)?-7 7/S X37 TOWN OF�El VILLAGE D4N1e1s f Oa <br /> II. TYPE OF BUILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family 3 OR ❑ Public(Specify): <br /> III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2.3 or 4,it applicable) <br /> 1. a. ® 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. L Conventional b. ❑ Alternative c. ❑ Experimental <br /> 2. a. ❑System- b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. El IGP <br /> In-Fill Tank <br /> V. ABSORPTION SYSTEM INFORMATION: (Check one) <br /> 1. a. 16 seepage Bed b. ❑See a e 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): 9 <br /> 3- 3- 3 6 1v (0,70 ! 1; Feet X Pi ivate ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in allons Total #ot Prefab. Fiber- 1E:1 <br /> INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Stee glass Plasti <br /> Tanks Tanks / strutted <br /> Septic Tank or HoldingTank l00 /�P C.On f ❑ <br /> Lift Pum Tank/Siphon Chamber ❑ <br /> VII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility folinstallation of the private sewage system shown on the attached plans. <br /> Plumber's Na a(Print): PI mber's ignatu e:( Stamps) MP/MPRSW No.: Business Phone Number: <br /> k e(s >° <br /> PI is Address(Stree,City tat Zi <br /> �.z p Code: Name of Designer: <br /> e r lc/I 8s3 <br /> VIII. SOIL TEST INFORMATION <br /> Ce <br /> ,Mi �l Tesler(CST)haNa e CST#3+ <br /> / j <br /> C ADDRESS(Street,City,Siate,Zip Code) Phone Numb r: <br /> sh , t,<JLS �s 3 -7/ X950 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> (`y/� ❑ Disapproved Sanitary Permit Fee Groundwater ate ISS 11 .Agent Si nature(No Stamps) <br /> X Approved ❑ Owner Given Initial Surcharge Fee _ <br /> Adverse Determination <br /> _460. 00 a5.pd -al-k' 771cr�L� <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 />