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�ILHR SANITARY PERMIT APPLICATION CO Y <br /> In accord with ILHR 83.05,Wis. AdmCode <br /> ST TE SANIT R P R <br /> . MIT# <br /> rl <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D. MBER <br /> 8'h 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 PROPERTY LOCATION <br /> j�Gii /�1 4 Gr � c rJ �fY G S'W Y. Alt '/a, S 7 T yQ, N, R � E (or) W <br /> PROPERTY OWNER'S MAILING ADDRESS/ �/ LOT NUMBER BLOCK NUMBER SUBDIVISI N NAME n <br /> ? T .r Lt « COU 4u VA Fill, •1J 4hr 'Ylrl r-T <br /> CITY,STATE ZIP CODE PHONE NUMB��E//R CITY / NEARS T OAD,LAKE OR LANDMARK <br /> SQ�4 C 1..4 Lt. SS.3 /'' �•$b VTOWN ILLAGE: <br /> 11. TYPE OF BUILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family C-- 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 BE 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. ZIConventional b. ❑Alternative C. ❑ Experimental <br /> 2. a. ❑System- b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy i ❑ Mound f. D IGP <br /> In-Fill Tank <br /> V. ABSORPTION SYSTEM INFORMATION: (Check one) <br /> 1. a. ®Seepage 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(Square Feet): / ISI <br /> Ll0 S �L� Feet P ivate ❑Joint ❑ Public <br /> / yx <br /> VI. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Ste I glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank M C_ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ 1 ❑ <br /> VII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Pluybar's Name(Print): PIu is Signature:(No Stamps) MP/MPRSW No.: Bu iness Phone Number: <br /> o c is $ b 6. yi,s <br /> Plumber' Address(Street,City,State,Zip Code): Nam f Designer: <br /> VIII. SOIL TEST INFORMATION <br /> Certified Spil Tester ST)Nam CST# <br /> Oar e- I F - c /� ch_ (' 3 c <br /> CST's ADDRESS(Street,City,State,Zip Code) Phone Num r: <br /> 1__-2-) -e,b S7` •r wit r , IL - 'A(r7 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved S nary Permit Fee IGroundwater ate [as g gent Si nature No Stamps) <br /> A roved ❑ Owner Given Initial (x� �/�y7�) Surrc�harge Fee rX7/ <br /> PP Adverse Determination `+O• `q_` OIJo� I.J. <br /> u <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 />