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�ILHR SANITARY PERMIT APPLICATION GNTY <br /> _•�m� �_ In accord with ILHR 83.05,Wis. Adm. Code ST TESANITARY PER IT# <br /> 13_CV0 <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ST TE PLAN I.D.NU ER <br /> 8'%x 11 inches in size. <br /> -See reverse side for instructions for completing this application. PETITION <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. F R VARIANCE F-1 <br /> YES ❑ NO <br /> PROPERTY OWNER PROPERTY LOCATION <br /> Four e ,sea/ A/E 'l4 A/u./(/4, S /8 T S/O, N, R 140 E(or)eV <br /> PROPERTY OWNER'S MAILING ADDRESS LOT NU BER BLOCK NUMBER SUBDIVISI N NAME C0' <br /> /-o �i n:3 QilC! bn::5 <br /> CITY,STATE / ZIP CODE�7 PH/O_NE NUMBpEyR/, CITY L / NEAREST OAD,LAK 9R LANDMARK <br /> incl/ lm `WgE Z/: �r 7-7 VILLAGE: CIQn� /ow f VCr <br /> II. TYPE OF BUILDING OR USE SERVED: L� ^/ <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.%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. XConventional b. ❑Alternative C. ❑ Experimental <br /> 2. a. ❑System- b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. 0 IGP <br /> In-Fill Tank <br /> V. ABSORPTION SYSTEM INFORMATION: (Check one) <br /> 1. a. X 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): PROPOSED(Squar/elFeet): �7 I1 <br /> 3 Y/� Tr• Y�`f *j• ��• / Feet d rivate ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exp . <br /> INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic Appp <br /> Tanks I Tanks structed <br /> Septic Tank or Holding Tank — So T ❑ <br /> Lift Pump Tank/Siphon Chamber 4 H LJ4T E❑ ❑ 1 H1 ❑ <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.: BL siness Phone Number: <br /> de 3341,,/ I 7/S S�lolo 7�?Plo <br /> Plumber's Address(Street,City,State,Zip Code): Name of Designer: <br /> X a u/eh.-5 bc/r , IF bt/Qde ,eu3/17 <br /> .,� <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST Name CST# <br /> U/OCde &1o'Ao%-n <br /> CST's ADDRESS(Street,City,State,Zip Code) Phone Num er: <br /> o?as /e,6_31er X41- sr1K3 7/cs �lclr - 7-?9lp <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee Groundwater al Iss Agents n r (No Stamps) <br /> Approved SurchargebF� 86 <br /> ❑ Owner Given Initial F�1hi'� O-) MID <br /> Adverse Determination VU r ✓ <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,Plumbs <br />