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�ILHR SANITARY PERMIT APPLICATION CDt Y e <br /> In accord with ILHR 83.05,Wis. Adm. Code <br /> STATE SANITARY PERMIT# <br /> X15 <br /> —Attach complete plans (to the county copy only)for the system, on paper not less than STATE PLAN I.D.NUMBER <br /> 8'%x 11 inches in size. — <br /> —See reverse side for instructions for completing this application. PETITION <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES ❑ NO <br /> PROPERTY OWNER PROPERTY LOCATION <br /> C/a '/a, S T , N, R 16 E (Dr) <br /> PROPERTY OWNER'S MKILING ADDRESS LOT NUMBER BLOCK NUMBERSUBDIVISION NAM <br /> x a '�_-- �pf <br /> CITY S ATE _ ZIP CODE PHONE NUMBER CITY NEAREST A LAK OR LANDMARK <br /> eYk L S1,127-1"1 <br /> _1 0 VILLAGE : !/ , <br /> II. TYPE OF BUILDING OR USE SERVED: ® /JJ� <br /> Number of Bedrooms if 1 or 2 Family OR XPublic(Specify): 0 Z <br /> III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4, if applicable) <br /> 1. a. W 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 M <br /> jA 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. XSeepage Bed b. ❑Seepage Trench c. ❑ See a e Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 14. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): <br /> . 15 Feet .Private ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION ew xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App- <br /> TN <br /> anks Tanks structed <br /> Se tic Tankor HoldinTank ❑ ❑ ❑ <br /> Lift Pum Tank/Siphon Chamber L-1 ❑ ❑ <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): Plu is ignature: No Stamps) P'RRSSJW No.: Business Phone Number: <br /> Y� �l �3 iS <br /> ,11 <br /> u \ddress(Street,City, tate,Zip Code): Name of Designer: <br /> er f�' $O <br /> VIII. SOIL TEST INFORMATION <br /> Certified it Tjpster(CST)Name CST <br /> r # 6 4i� / <br /> CST's ADDRESS(Street,City,State,Zip Code) Phone Number: <br /> IN_re�po_ 91h1r n 9 6117 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapprovetl S nary Permit Fee Groundwater ate Iss g gent Signature(N Stamps) <br /> Approved ❑ Owner Given Initial /1Tl S co�harge Fgee� ^�L�-yt <br /> Adverse Determination ° lJv �Ow `" , <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 />