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�ILHR SANITARY PERMIT APPLICATION D UNT <br /> In accord with ILHR 83.05,Wis.Adm.Code L--Lu(nom <br /> STATE SANITARY PERMIT# <br /> g__7f_1337Vel <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than ST TE PLAN I.D. UMBER <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 ❑YES ❑ NO <br /> PRO ERTYOWNER PROPERTY LOCATION <br /> 4-r w Jr � ''/a$ /4, S T3 , N, R E (or <br /> PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER B OCK NUMBER SUBDIVISION NAME <br /> 2tr t � 3a <br /> CITY,STATE ZIP CODE PHONE NUMBER CITY NEAREST ROAD,LAKE.?.R LANDMARK <br /> C fZf,10 LA)t <br /> yt �Z �v VILLAGE : wN <br /> 4& <br /> II. TYPE OF BUILDING OR USE SERVED: <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. 11Reconnection 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. IGP <br /> In-Fill Tank <br /> V. ABSORPTION SYSTEM INFORMATION: (Check one) <br /> 1. a. ee a e Bed b. ❑Seepage Trench c. ❑ Seepage Pit <br /> 2. PER OLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet). <br /> Y a Feet Urrivate ❑Joint ❑ Public <br /> CAPACITY <br /> VI. TANK Site <br /> trioallons Total #Of <br /> Prefab. Fiber- Exper. <br /> INFORMATION a xisting Gallons Tanks Manufacturer's Name Concrete Con- Ste glass Plastic App <br /> ank Tanks structed <br /> Se tic Tank or Holding Tank iUt El ❑ <br /> Lift Pump Tank/Siphon Chamber. CO/C- AIS ❑ 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): Iu er's Signature:( o tamps) P/MPRSW No.: Bt siness Phone Number: <br /> f e 7 3 IS- <br /> Plumber's Ad es Street,City,State,Zi Code): Name of esigner: <br /> _7a3 1 lge-A) 72t-- <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soi ester(CT Name CST# <br /> 5ill K- 1/vs 3 7 <br /> CST's ADD RE S(Stye 1,City,State,Zip Code) Phone Num er. <br /> S <br /> IX. OUNTY/DEPARTMENT US ONLY <br /> ❑ Disapproved Sanitary Permit Fee I Groundwater ate Issuing Agent Si name(No Stamps) <br /> proved ❑ Owner Given Initial I/� (�� S rcharge Fee <br /> Adverse Determination "" "-� �S' "" 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 Piumbing,Owner,Plumber <br />