Laserfiche WebLink
Q �ILHR SANITARY PERMIT APPLICATION CO TY <br /> In accord with ILHR 83.05,Wis. Adm. Code <br /> ST ESANITARYPI MIT# <br /> �5 <br /> -Attach complete plans(to the county copy only)for the system, on paper not less than STATE PLAN 1'13.NUMBER <br /> 8'%x 11 inches in size. <br /> -See reverse side for instructions for completing this application. PET TION <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. FOF VARIANCE ❑YES ❑ NO <br /> PR PERTYOWNER PROPERTY LOCATION <br /> 7r t d SW'/4 SE 1/4, S a g TV QV, Rf (or) W <br /> PRO ERTY O NER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISIONNAM <br /> Wt 33 s g; W#tj 4r c, . <br /> C ,STATF, ZIP CODE PHONE NUMBER CITY NEAR T <br /> IT AD,LAKE OR LANDMARK <br /> VW <br /> /T// n t S, #E ) 7 S 81y. VILLAGE <br /> IL TYPE OF ILDING OR USE SERVED: <br /> Number of Bedrooms if 1 Or 2 Family I? OR ❑ Public(Specify)#0-Z0—q,,I 0/^ <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 Agreemer t to County Copy. <br /> IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2) <br /> 1. a. WConventional 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. See a e Bed b. ❑Seepage Trench c. ❑ Seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WA ER SUPPLY: <br /> h(Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): 1� <br /> O _ 4P/S- ILl P ��• $ Feet Pri ate ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in gallons Total #of Manufacturer's Name Prefab, Con- Steel Fiber- Plastic Exper. <br /> INFORMATION New xisting Gallons Tanks Concrete glass App. <br /> Tanks Tanks structed <br /> Septic Tank or Holding Tank K I /a 04 ) * hl C <br /> Lift Pump Tank/Siphon Chamber S o /L(C ❑ ❑ <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' ignature:(N Stamps) MP/MPRSW No.: Busi ass Phone Number: <br /> e rtc Cfa 01� 01SN /1^ 966Y/-r07 <br /> Plumber's dress(Street,City,State,Zip Code): Name of D ner: <br /> S` <br /> tir <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester Tester(CST)Name CST# <br /> t C rrc�T l�'ln S <br /> CST's ADDRESS(S reef,City,State,Zip ode) Phone Number <br /> w 6 S 7 r ii ka' S- <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee Groundwater ate Iss Agent Sign ture(No Stamps) <br /> Approved ❑ Owner Given Initial ��}y ry�'�`� ��,, �SSg1rcharge Fee <br /> Adverse Determination II '-31J' Vv -B5S•CTD I <br /> X. COMMENTS/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.03/86) Di3TRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber <br />