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C DILHR SANITARY PERMIT APPLICATION coo Y <br /> In accord with ILHR 83.05,Wis.Adm. Code <br /> tC s STPi SANITARY P RMI <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBER <br /> 8'fz x 11 inches in size. <br /> -See reverse side for instructions for completing this application. PETITION <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES ❑ NO <br /> PROPERTY OWNER PROPERTY LOCATION <br /> C�,A 1 1 F2DRESS U6 '/4 5Lt/ '/4, S 3 l T y0, N, R ( E (or <br /> PROPERTY OWNER MAILING ADLOT NUMBER BLOCK NUMBER SUBDIVISION NAME <br /> 154IN [!TL k0 n>o rt 11 V- fS-zl' Nla N/A N/ft <br /> CITY,STATE ZIP ODE PHONE NUMBER CITY NEAREST ROAD,LAKE OR LANDMARK <br /> VILLAGE : <br /> If. TYPE OF BUILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family OR ❑ Public(Specify): <br /> 111. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) <br /> 1. a. XNew 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. El Experimental <br /> 2. a. ❑System- b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP <br /> In-Fill Tank <br /> V. ABSORPTION SYSTEM INFORMATION: (Check one) <br /> 1. a. W 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(Squar Feet): ��-7 <br /> 6) 7 / JFeet <br /> Q Private El joint El Public <br /> CAPACITY Site <br /> VI. TANK in allons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- plastic Exper. <br /> INFORMATION New xisting Gallons Tanks Concrete glass App. <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank '75 1 750 7 -M- I ❑ <br /> LittPum Tank/Si hon Chamber OF ❑ Ll I ❑ <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): PIu ature:(No lam s) MP/MPRSW No.: Business Phone Number: <br /> LIA)Akf> E ti 307 �� 2NS� 3 <br /> Plumber's Address(Street,City,Slate,Zip Code): Name of Designer: <br /> VIII. SOIL TEST INFORMATION <br /> Ce dONil steDr(CST� . ppo� � CST# / <br /> CST's ADDRESS(Street,City,State,Zip de) Phone Number: <br /> laNt. 3 ax 470I< <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapprovetl Sanitary Fee Groundwater ate Issuing gent Signature(No Stamps) <br /> Approved F-1 Owner Given Initial 61e ADY Sur a ggg e� B ( ��v <br /> Adverse Determination �3��33� w (llJ or / f��Yy�j�,�✓� r_I/I <br /> X. COMMENTS/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Ong.aal to County..One Copy To:Bureau of Plumbing,Owner,Plumber J <br />