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UILHR SANITARY PERMIT APPLICATION c TY r <br /> 17 ' In accord with ILHR 83.05,Wis.Adm. Code ST TESANITARY ERMIT# <br /> 5 <br /> —Attach complete plans(to the county copy only)for the system, on paper not less than ST NTE PLAN I.D.NUMBER <br /> 8'h x 11 inches in size. <br /> —See reverse side for instructions for completing this application. PETITION <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES ❑ NO <br /> PROPERTY WNER -�- QQ // FROPERTY(L�OCATION <br /> Or l!o ,4tt r /� PFl� SL,) N./V %, S T /d , N, R �0 !(or)W <br /> PROk ERTY OWNER' AILING R SS LOT NUMBER BLOCK NUMBER SU IVISI N NAME - ,� <br /> kT I 9 Al rrl A t t e r/ A/dl rs <br /> CITY,STQ�E ZIP CODE PHONE NUMBER CITY / NEAREST O ,LAKE OR NQMARK <br /> titKK VILLAGE fil , TOWN OF <br /> 04 QAJ u to <br /> II. TYP F BUILDING OR USE SERVED: VVV <br /> Number of Bedrooms if 1 or 2 Family 2 OR ❑ Public(Specify): <br /> Ill. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) <br /> 1. a. V1 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 Agreement to County Copy. <br /> IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2) <br /> 1. a. ®'Conventional b. ❑Alternative C. ❑ Experimental <br /> 2. a. ❑System- b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound I. El IGP <br /> In-Fill Tank <br /> V. ABSORPTION SYSTEM INFORMATION: (Check one) <br /> 1. a. Q See a e 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 /> (Min tes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): ` <br /> ! U T/ T 1,, Feet F rivate ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> er <br /> in gallons Total #of Manufacturer's Name Prefab. Con- Steel LFiber- Plastic App. <br /> INFORMATION New xisting Gallons Tanks Concrete structed App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank 7sn `r' <br /> Lift Pum Tank/Si hon Chamber El 1 ❑ ❑ <br /> VII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility tar installation of the private sewage system shown on the attached plans. <br /> Plumber's Name(Print): Plumber's Signature:(No Stamps) MP/MPRSW No.: Etisiness Phone Number: <br /> 40 4 <br /> 'vy « s odor �r �66yit � <br /> Plumber's dres Street ity,State,Zip Code): Nar/pes of esigner: <br /> /0 5 `Pf` w' r- `� <br /> VIII. SOIL TEST INFORMATION <br /> Certified oil Tester CST)Name CST# <br /> V,(C I Q <br /> CST's ADD ESS(Street,City,Statd,Zip Code) Phone Number: <br /> Wit �lTr- W1, s- s- F9 /5- 9616- 5//SI <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sa itary Permit Fee Groundwater ate Issuing gent S gnature(No Stamps) <br /> proved ❑ Owner Given Initial Su charge F//yyee//�� I a <br /> Adverse Determination ��� �'vv II—I� mA.v✓t� <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,Plumbe <br />