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fl �ILHR SANITARY PERMIT APPLICATIONCD <br /> �n <br /> In accord with ILHR 83.05,Wis.Adm. Code <br /> S ATE SANITARY PERMIT <br /> .o,..,.,. r I�_Jlt7 <br /> —Attach complete plans(to the county copy only)for the system, on paper not less than S ATE PLAN 1.D. MBER <br /> 8'h x 11 inches in size. <br /> —See reverse side for instructions for completing this application. p TITION <br /> 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES ❑ NO <br /> PROPERTY<OWNER pp PROPERTY LOCATION <br /> SE 14. .SUA., S 49 T 0110, N, R E (or <br /> PROPERTY OWNER'S MAILING ADDR SS LOT NUMBER BLOCK NUMBER I 5 BDIVIS ON NAME <br /> so — &/ow Avco PihCS <br /> CITY,STATE / ZIP CODE PHONE NUMB(�EI CITY NEARESOAD,LppK�E OR LANDMARK <br /> //7C�C./e rn.V �i�3 ��a s7' VILLAGE : <br /> or <br /> 14 N/ .C/Ver <br /> 11. TYPE OF BUILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family 1-2 beo�ic�ns OR ❑ Public(Specify): <br /> III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) <br /> 1. a. X New b.❑ Replacement c. ❑ Replacement of d. ❑ Reconnection of E.El 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 Agreem nt to County Copy. <br /> IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2) <br /> 1. a. Y"Conventional b. ❑ Alternative C. ❑ Experimental <br /> 2. a. ❑System- b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound I. ❑ IGP <br /> In-Fill Tank <br /> V. ABSORPTION SYSTEM INFORMATION: (Check one) <br /> 1. a. 9 Seepage Bed b. ❑Seepage Trench c. ❑ See a e Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 14. ABSORPTION AREA 5.SYSTEM ELEVATION 6. W NTER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square F et): PROPOS D(( quare/F+e/et): <br /> 3 Y�0 �' �r rT' 7(O•`u Feet �Imo' <br /> rivate ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> I <br /> all <br /> Total of Manufacturer's Name Prefab. Con- Steel Fiber- plastic Exper. <br /> INFORMATION jTanwks <br /> xisting Gallons Tanks Concrete glass App. <br /> Tanks �structed <br /> Septic Tank or HoldingTank D — 750 1 7177G <br /> Lift Pump Tank/Siphon Chamber. ❑ <br /> I Li <br /> VII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plan <br /> Plumber's Name(Print): Plumber's Signature:( Stamps) MP/MPRSWNo.: I Business Phone Number: <br /> k/Qde P,Fsfio/m 3310/ 7/S PlOG-7��1v <br /> P <br /> Xlu bar's Address(Street,City,State Zip Code): Name of Designer <br /> / des t tkb3� C u/1 �1P9 kloot &"00124,1,n <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)yame CST# <br /> vlode l'sZ071 3 F-3 <br /> CST's�ADDRESS(Street,City,State,Zip Code) Phone Number <br /> IiIJX o?as )n/ef60fee, WZ 671,093 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee Groundwater at Iss ng gent Sin (No Stamps) <br /> •Approved ❑ owner Given Initial CoSurcharge Feee <br /> r <br /> Adverse Determination `I Fe <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 />