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D1LHR SANITARY PERMIT APPLICATION C& <br /> 1n accord with ILHR 83.05,Wis. Adm. Code <br /> S ATE SANITARY ERMIT# <br /> I 8 136 <br /> -Attach complete plans(to the county copy only)for the system, on paper not less than S ATE PLAN I.D.NUMBER <br /> 8'h x 11 inches in size. <br /> -See reverse side for instructions for completing this application. P TITION <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES ❑ NO <br /> PROPERTY OW ER PROPERTY LOCATION <br /> er-a /r a n 'i Ij u)'/aSW '/a, S T y/, N, R 47 1 (or W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVIS ON NAME <br /> 0 '.%. Me K r t I N/ A C-9ft, U60 <br /> CITY,STATE ZIP CODE PHONE NUMBER Li CITY NEAREST ROAD,LAKE OR LANDMARK <br /> Ii. �O MTOWN <br /> llf j 0 I ❑ VILLAGE: S W[• M, H. Y t"'lJ- C / <br /> II. TYPE OF BUILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family Z 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. [X Replacement c. ❑ Replacement of d. ❑ Reconnection of c ❑ 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 Agreem nt 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 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. TER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): Q l� <br /> 3 // 0 7 �— < � Q Feet Dil rivate ❑Joint El Public <br /> VI. TANK CAPACITYin gallons Total #of Prefab. Site Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Ste glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank Z ( C <br /> Lift Pump Tank/Siphon Chamber <br /> VII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plan . <br /> Plumber's Name(Print): (No Stamps) <br /> Plu �S /JMP/MPRSWNo.: Bsness Phone Number: <br /> 0S� <br /> Ltnt <br /> 7 .1— Ly <br /> Plumber's Address(Street,Citq,State,Zip Code): Name of Signe <br /> _ yf e <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name CST# <br /> Itr �¢ 4rL -33a �- <br /> 's ADDRESS(Street,City,State,Zi Code) Phone Num ler: <br /> '1, ,- - -3 V - ';I <br /> F o <br /> X. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved I S itary Permit Fee Groundwater ate Iss ng gent S gna No Stamps) <br /> Approved F-1Owner Given Initial on S charge Fee <br /> Adverse Determination l,,,r�J ,95, co <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,Plumbe <br />