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DILHR SANITARY PERMIT APPLICATION CoY <br /> _ In accord with ILHR 83.05,Wis. Adm. Code jrnobbT <br /> mmome STATE SANITAFERMIT <br /> IC6-770 613, <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I. UMBER <br /> 8%x 11 inches in size. <br /> —See reverse side for instructions for completing this application. PETITION <br /> 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOF VARIANCE ❑YES ❑ NO <br /> PROPERTY OWNER PROPERTY LOCATION <br /> 9� e�tNY A Gv « e SW '/, PI— %, S rl TVO, N, R (p 11 (or)W <br /> PROPERTY OWNER'S MAILING ADDRESS 50LOT NUMBER BLOCK NUMBER SUBDIVISIO 4 NAME [� <br /> Er YS 4 V, A A ¢nr /wo nlfi <br /> CITY,STATE ZIP CODE PHONE NUMB yye� pr� CITY / NEAREST R D,LAKE LANDMARK <br /> I 4 .SSY/0 'foF7- p VILLwN AGE : O V.f[4t d OW 16rJ 0-4 r <br /> II. TYPE OF BUILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family f OR 7 Public(Specify): <br /> III. PURPOSE OF APPLICATION: (Check only one in#1. C eck#2, or 4,if applicable) <br /> 1. a. New b. El Replacement Replac ant of d. ❑ Re nn ction of e. Repair of an <br /> System System Septic ank Only an t g System Existing System <br /> 2. ❑ A Sanitary Permit was previousl ' su Per # sued <br /> 3. ❑ An Existing System has been i ecte d conditions meet mini qu a ants. <br /> 4. ❑ The System is shared by more an one owner/building. Attac o Owner hip greemer t to County Copy. <br /> IV. TYPE OF SYSTEM: (Check only one in#1 an y one in#2) <br /> 1. a. 10 Conventional elding <br /> )hpative C. ❑ Expe en I2. a. ❑System- b. ❑ HPit Privy ❑ V It Privy e. ❑ Mound f. IGP <br /> In-Fill T .. <br /> V. ABSORPTION SYSTEM INFORM (Check one) <br /> 1. a. ® Seepage Bed b. ❑Se a Trench c. D79bWage Pit <br /> 2. PERCOLATION RATE 3. SORPTION AR 4. AB PTION REA 5.SYSTEM ELEVATION 6. WATER SUPPLY: <br /> (Minutes per inch): REQ R are Feet): PROP re Feet): <br /> Feet ❑Pri ate ❑Joint ❑ Public <br /> VI. TANK CA by, Y Site <br /> in aN Total #of facturer's Name Prefab. Con- Steel LEI <br /> plastic Exper. <br /> INFORMATION New stl Gallons Tan Concrete App. <br /> Tanks wanks structed <br /> Septic Tank or Holdingk S /�'� �- ❑ <br /> Lift Pum Tank/Si hon C ❑ ❑ ❑ <br /> VII. RESPONSIBILITY STA WT91T <br /> I,the undersigned,assume responsibility for ins ation of the ivate sewage system shown on the attached plans. <br /> Plumber's Name(Print): Plumber's S�ig 4� o Stamps) MP/MPRSW No.: Business Phone Number: <br /> JD a csve rt c t nr GCs .�{Q D 0 s 9 !� 9(e6-y/S'� <br /> Plumber's Address(Street,Ci ,State,Zip Code): V Name of Designer: , <br /> VIII. SOIL TEST INFORMATION <br /> Ce�r'j'ed koil Tester( ST)Name CST# <br /> /L/ c ll.t� r 3k 7 O <br /> CST's ADDRESS(Street,City,State,Zip Code) Phone Numbe : <br /> vl�,� w `f S f" <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved I Sanitary Permit Fee 4Grundwater ate Issu g ant Sig atu oStamps) <br /> Approved ❑ Owner Given Initial Cin /Qr� charge,Fgee�� i <br /> Adverse Determination • �j'u/ <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 />