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DILHR SANITARY PERMIT APPLICATION ou <br /> In accord with ILHR 83.05,Wis.Adm.Code <br /> STAT SANITARY PE IT# <br /> as <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBER <br /> 8'h x 11 inches in size. <br /> —See reverse side for instructions for completing this application. PETITION <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. OR VARIANCE ❑YES ❑ NO <br /> PROPERTY OWNER LPR�OPERTYTIONm Ki Al-e L S e rJ '/4, S .? T y0, N, R / ! (or) W <br /> PROPERTY OWNER'S MAILING ADDRESS BLOCK NUMBER SUBDIVI ION NAME <br /> oCITY,STATE ZIPCODE PHONENUMBER / NEARES ROAD,LAKE OR LANDMARK <br /> I, Ge0 � CyTB 91.L 7�Oy�o7 P Ir4t At viGf CL�\ �1 <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. ❑ New b. [X Replacement c. ❑ Replacement of d.❑ Reconnection of p ❑ 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. ❑ Experimental I'I <br /> 2. a. ❑System- b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound fl ❑ 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. ATER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): <br /> C7 (f � )L-- ���� Feet l��Private ❑Joint ❑ Public <br /> VI. TANK CAPACITY #of Prefab. Site Fiber- Exper. <br /> in gallons Total Manufacturer's Name Con- S[ el Plastic <br /> INFORMATION New xisting Gallons Tanks Concrete glass App. <br /> Tanks Tanks strutted <br /> Septic Tank or HoldingTank <br /> Lift Pum Tank/Si hon Chamber <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 is Signature:(No Stamps) MP/MPRSW No. E usiness Phone Number: <br /> hoe p C7�ra r 6 ? 7��r X 66 - l�7 <br /> Plumber's Address(Street,Ci y,State,Zip Code): Name of si er: <br /> w,e6ST r U1 S �! P¢ <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name CST# <br /> k- -h � y � -7 <br /> CST's ADD ESS(Street,City,Stat ,Zip Code) Phone Number: <br /> W, f . 0 S7 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee Groundwater ate Issui gent ign t e(No Stamps) <br /> Approved ❑ Owner Given Initial /� S rcharCge�Fgee� ate (x� <br /> Adverse Determination "-"'�� �S•�/ <br /> X. COMMENTS/REASONS FOR DISAPPROVAL: L <br /> SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber <br />