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SANITARY PERMIT APPLICATIONY <br /> DILHR In accord with ILHR 83.05,Wis.Adm.Code UC(� " <br /> '....,-,.�..e. STATE SANITARY PERMIT <br /> 1 21� Im <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. <br /> PETITION <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. I FOR VARIANCE ❑YES ❑ NO <br /> P OPERTY OWN {�. PROPERTY LOCATION t/ <br /> ti r. 74 J� C,#j NEYa //CYa, S T N, R /J E (or) W <br /> PROPERTY OWNER'S MAIUING ADDRESS LO�t%tv1.6ER BLOC%yUMBER SUBDDVISIONNAME <br /> 41717 -16 /yY1lJf S '/LL`` It/p <br /> CITY,STATE ZIP CODE PHONE NUMBER CITY NEAREST ROAD,LA E O LANDMARK <br /> O VILLAGE : Q -' <br /> 4tdivn r1 s a 1/ <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. PVT Replacement c. ElReplacementof 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 G. ❑ Experimental <br /> 2. a. ❑System- b. ❑ Holding c.L1 Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP <br /> In-Fill Tank <br /> V. ABSORPTION SYSTEM INFORMATION: (Check one) <br /> 1. a. r,%Seepage Bed b. ❑Seepage Trench c. ❑ Seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 15.SYSTEM ELEVATION 6. WATER SUPPLY: <br /> (Miuu)tes per inch): REQUIRED(Square Feet): PROPOSED Square Feet): Q �7l <br /> T 6 / .S— & ALI L �' Feet Lp Private ❑Joint ❑ Public <br /> CAPACITY Site <br /> VI. TANK ng allons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. <br /> INFORMATION New xistin Gallons Tanks Concrete glass App. <br /> Tanks Tanks structed <br /> Septic Tank or HoldingTank S r �-C. ❑ <br /> Lift Pum Tank/Siphon Chamber ❑ ❑ ❑ ❑ <br /> VII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plans. <br /> PI bar' Name(Print): PI er's ignature: Sla ps) MP/MPRSW No.: Business one Number: <br /> lumber's A dres (Street,Cit ,State,Zip Code): Na f Desgner: <br /> %k � c-� _ LG �g C, <br /> VIII. SOIL TEST INFORMATION <br /> Ce ied s l Tester CSJ)Name CST# <br /> rlC � � h1 7 3 . <br /> 's ADD SS( treat,City,State,Zip C e) � Phone Number: <br /> a EE yi i `7 <br /> IX. COUNTY/DEPARTMENT USE O LY <br /> Disapproved Sanitary Permit Fee Groundwater Is Issui hent Signature, <br /> 'oStamps) <br /> r <br /> pproved ❑ Owner Given Initial Surcharge Fee � <br /> a ) ; 7 <br /> Adverse Determination l� �� ` � G - <br /> X. COMMENTS/REASONS FOR DISAPPROVAL: / <br /> SBD-6398(formerly Plb-67)in 03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber <br />