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DILHR SANITARY PERMIT APPLICATION <br /> s In accord with ILHR 83.05,Wis.Adm.Code r <br /> STATE SANITARYRMIT# <br /> III P <br /> 1 a_736 <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than ST TE PLAN I.D.NUMBER <br /> 8'h x 11 inches in size. <br /> —See reverse side for instructions for completing this application. PE FITION <br /> 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. Fo VARIANCE ❑YES ❑ NO <br /> PROPERTY OWNER PROPERTY LOCATION <br /> N4,h'/4 uE '/4, S Z T 0, N, R (or)W <br /> PR PERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK N MBER SUBDIVISI NAME <br /> 47, <br /> CITY,SE ZIP CODE PHONE NUMBER CITY AA N ST O D LAKE OR LAND ARK <br /> Lt[CTAT41 IS- VILLAGE TOWN OFU Q Qir (4) p <br /> It. 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. I,New 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. tikonventional 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. X 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(Square Feet): r� <br /> I d Y S ��" Feet A" 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- Ste I glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank 7'So ?SC 'T /t't C ❑ <br /> Lift Pump Tank/Siphon Chamber SOt SCC T L ❑ ❑ ❑ <br /> VII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plans. <br /> PIA' <br /> Name(Prin Plu i ature:(No m s) [MPIMPRSW No.: Business Phone Number <br /> :/, <br /> ,V`I ( lto C3G—fis ICU-- Y/`( <br /> Plumber's dre (Street,CitV,State,Zip Code): /, Name of Designer: <br /> SY <br /> VIII. SOIL TEST INFORMATION <br /> Cerci 'ed Soi Tester(CST) me � p ,� CST# <br /> !'f C' \YNJ <br /> CSTs ADDRESS Sireel icy,State,Zip Code, Phone Numb r: <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> rrrr����//// <br /> F-1DisapprovedSanitary Permit Fee Groundwater ate Issui gent Si natur (No Stamps) <br /> L Approved ❑ Owner Given Initial '4 6D r/V/) rcharge Fee ^J <br /> / ' Adverse Determination vel/ lLly IM-1 <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 />