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C)ILHR SANITARY PERMIT APPLICATION COU�Ay-'�yTTY� <br /> .o I LH_ In accord with ILHR 83.05,Wis.Adm. Code <br /> STATE SAN IT YPERMIT <br /> CJ <br /> )� O <br /> —Attach complete plans(to the county copy only)for the system, on paper not less than STATE PLAN I.D.NUMBER <br /> 8'/z x 11 inches in size. <br /> —See reverse side for instructions for completing this application. PETITION <br /> 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES 5d NO <br /> PROP€RTY OWNER PROPERTY LOCATION <br /> h4� � 1c5 SC SW'/< /Vftn/a, S I T ON, R �p $i(or) W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME <br /> 0 r F 1 '4 X'X <br /> CITY, TATE ZIP CODE PHONE NUMBER CITYST TOWN OF: F / NEAREST ROAD,LAKE OR LANDMARK <br /> E] VILLAGE : 4?n Z-# L <br /> It. TY OF BUILDING OR USE SERVED: �I <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. ❑ 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. ElAn 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. gConventional 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. WSee a e Bed b. ❑Seepage Trench C. ❑ Seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 15.SYSTEM ELEVATION 6. WATER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): 9 <br /> Q 3 f� / Feet 4?Private ❑Joint El Public <br /> VI. TANK CAPACITY Site <br /> in aons Total #of Prefab. Fiber- <br /> 11 Exper. <br /> INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks structed <br /> Septic Tank or Holding Tank tv Lj LJ ❑ <br /> Lilt Pump Tank/Siphon Chamber I ❑ ❑ Li Li I ❑ I ❑ <br /> VII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Pl/u1���ber's Name(Print): Plumber's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> 10 �e rt' O S` is. <br /> Plumber's ddr ss(Street,City, tate,Zip Code): Na f D signer: <br /> Lu C S' <br /> VIII. SOIL TEST INFORMATION <br /> Cert''ed S 'I Tester(CST)Name CST# <br /> d fr-1' ) 1 1-137 <br /> S 's D R S( tr et,City,State,Zip C de) Phone Number: <br /> /T l <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved I Sanitary Permit Fee Groundwater at Is 'ng Agent i nature(No Stamps) <br /> Approved ❑ Owner Given Initial 7ly�f Surcharge�Feeee <br /> Adverse Determination 4=��W - <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 />