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fl DILHR SANITARY PERMIT APPLICATION COUNTY <br /> In accord with ILHR 83.05,Wis. Adm. Code <br /> p s STATE SAN ITARY 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%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 /> ..1 ( � I C ✓ S' % Vt..' Ya, S l" T N, R SL(or) W <br /> PROPERTY OWNER'S MAILING ADDRESSLOTNUMBER BLOCK NUMBER SUBDIVISION NAME <br /> C C cr n 1 <br /> ITV,STATE ZIP CODE PHONE NUMBER CITY NEAREST OAD,/LAKE OR LANDMARK// <br /> VILLAGE : I( SS 47hr •t � 'p+ `t" <br /> on - <br /> It. 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 /> L1AT <br /> 1. a. New b. L31 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. Wonventional b. ❑ Alternative C. ❑ Experimental <br /> 2. a. ❑System- b. ❑ Holding c.11 Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ 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. WATER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): r <br /> 9 S� J Feet lt�Private ❑Joint El Public <br /> VI. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank C- ❑ ❑ <br /> Lift Pump Tank/Si hon Chamber I I I I I ❑ I Ll I ❑ I 1 1 ❑ <br /> VII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Plumber's Name(Print): PlyQber's Signature: o Stam s) MP/MPRSW No.: Business Phone Number <br /> VZ <br /> Plumber' Addr as(Stre t,CH ,State,Zip Code): Na a of Des gner: <br /> VIII. SOIL TEST INFORMATION <br /> C ed So' Tester(CST Name ) _ CST# <br /> O I c - .r <br /> CST's ADDR S(Str at,City,State,Zip CoreZ Phone Number: <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee Groundwater a <br /> F-1te Is s Agent Si n ure(No Stamps) <br /> Approved Owner Given Initial S rcharge Fee <br /> Adverse Determination15 <br /> � <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 />