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DILHR SANITARY PERMIT APPLICATION COUNTY <br /> In accord with ILHR 83.05,Wis. Adm. Code �v t e <br /> STATESANITARYP RMIT# <br /> 2%4 <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBER <br /> 8'/2 x 11 inches in size. <br /> -See reverse side for instructions for completing this application. P�TITION <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES ❑ NO <br /> PROPERTY OWNER PROPERTY LOCATION / <br /> /4 '/4, S 3 TYO , N, R /S E (or) <br /> PROPERTY OWNER'S MAILING ADDRESSLOT NUMBER BLOCK NUMBER SUBDIVIS N NAME <br /> 3a Go✓. X NA A <br /> CITY,STATE ZIP CODE PHONE NUMBER CITY NEAREST ROAD,LAKE OR LANDMARK <br /> u <br /> SJArld, mi <br /> O VILLAGE CA <br /> d Z Q <br /> 11. 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. ® Replacement c. ❑ Replacement of d. ❑ Reconnection of a.❑ 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 Agreemjent to County Copy. <br /> IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2) <br /> 1. a. X 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. ❑ See a e Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 15.SYSTEM ELEVATION 6. VVATER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): <br /> (o/_5 �� 9 0 Feet ®Private ❑Joint ❑ 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 /> Se tic Tank or Holding Tank /000 J0490 I I 1XI I ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber 0 I S DO 1 21 1 ❑ Li ❑ ❑ <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): PI tuber's Signature:(No SI s) MP/MPRSW No.: Business Phone Number: <br /> L7e L �e�scn Z 3 6U Y68-aGv <br /> Plumber's Aqdress(Street,City,State,Zi Co Name of Designee <br /> Y /4Y//7iJ <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name CST# <br /> o L Allo 3508 <br /> CST's ADDRESS reel,City,State,Zip Co e) Phone Number: <br /> a o n 8/,? ;t <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee Groundwater ate Iss Agent igru u (No Stamps) <br /> pproved ❑ Owner Given Initial Wn) lt��1�1J Su charge Fee <br /> Adverse Determination ��� O "r <br /> X. COMMENTS/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Orignal to County,One Copy To:Bureau of Plumbing,Owner,Plumber <br />