Laserfiche WebLink
QILI-IR SANITARY PERMIT APPLICATION CgNTY //�� <br /> In accord with ILHR 83.05,Wis. Adm. Code vrn PTT— <br /> STAT SANITARY PERMIT# <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than STATE 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 OWNER PROPERTY LOCATION <br /> 45. _nre vet, c'/I o -Ztc. 1A614NW '/4, S 9 T39 , N, R /7 �{e► <br /> PROPERTY OWNER'S MAILING AD ESS LOTNUMBER BLOCK NUMBER SUBDIVISION NAME <br /> 7113-5- Goc us-�- L/-/- <br /> ODE <br /> W CO <br /> DE PHONE NUMBER 0 <br /> ❑ CITY NEARES KEORLANDMARK <br /> VILLAGE idvY, <br /> PCI <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.;K 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. ❑ IGP <br /> In-Fill Tank <br /> V. ABSORPTION SYSTEM INFORMATION: (Check one) <br /> 1. a. Xseepage Bed b. ❑ seepage Trench c. ❑ Seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: <br /> ' / (Mi utes per inch): RE {1I RED(Square Feet): PROPOSED(Square Feet): 9 �^ IyI <br /> �"— 7 — ! �� T� ` �• J Feet Private ❑Joint El Public <br /> VI. TANK CAPACITY <br /> in allons Total Site P <br /> INFORMATION #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Expe <br /> New xisting Gallons Tanks Concrete strutted glass App. <br /> Tanks Tanks r�.yn� <br /> e ticT HoldingTank 1P LUt eSer ❑ ❑ ❑ <br /> Litt Pum Tank/Siphon Chamber ❑ ❑ ❑ ❑ <br /> VII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for I <br /> nstallation of the private sewage system shown on the attached plans. <br /> Plumber's Name(Print: Plu er's Si nature:( o mps) MP/MPRSW No.: Business Phone Number. <br /> 2(S 26f?F Qilr �KPS7�r� 7� f -�Y�Fl <br /> Plu b s Address(Street,City,S?te,Zip Code): Nam of De igner:�/' <br /> ebs4 ' <br /> VIII. SOIL TEST INFORMATION <br /> Certik-Aenster(CS ;r17Le / CST# <br /> CST' A DRESS(Street,City,State,Zi Cod ) Phone Number: <br /> COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved SEVqery Permit Fee Groundwaterate Issuing Agent Signature(No Stamps) <br /> Approved F-1OwnerGiven Initial y/t (,y�(�) Surcharge Fe. <br /> � /O /1'•n ' <br /> Adverse Determination W `v <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 />