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DILHR SANITARY PERMIT APPLICATION Gou Y <br /> In accord with ILHR 83.05,Wis. Adm. Code (r <br /> STATESANITAR PERMIT# <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBER <br /> 8'/s x 11 inches in size. <br /> —See reverse side for instructions for completing this application. PETITION <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES ❑ NO <br /> PROPERTY OWNER PROPERTY LOCATION <br /> Io & AXJ Y<, S/ T N, IR E (or) W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCE BER SUBDIVISION NAME <br /> 33Tc <br /> 1c� 4 o i44 �QofkllaL6N 1-zL_ �4—Q <br /> CITY,STATE ZIP CODE PHONE NUMBER CITY NEAREST ROAD,LAKE OR LANDMARK <br /> --- ^—_. Ise Y S VILLAGETOW : � GauL.L LIq- <br /> IL TYPE OF BUILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family f 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.`J �Replacement c. ❑ Replacement of d. ❑ Reconnection of e.ElRepair 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.%1C, <br /> onventional b. ❑Alternative c. ❑ Experimental <br /> 2. a. ❑System- b. ❑ Holding c.1:1 Pit Privy d. ❑ Vault Privy e. ❑ Mound f.i❑ IGP <br /> In-Fill Tank <br /> V. ABSORPTION SYSTEM INFORMATION: (Check one) <br /> 1. a.�ISeepalje Bed b. ❑Seepage Trench c. ❑ Seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 15.SYSTEM ELEVATION 6. WATER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): i PROPOSED(Square Feet): <br /> —G Feet private El joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in 11 ns Total #ofPrefab. Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Se tic Tank or Holdinci Tank 7-,5--6 rtL - ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ El 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): PI _ gnature:( St s MP/MPRSWWn No.: Business Phone Number: <br /> / <br /> Plumber's Address(Street,City,State,Zip Code): Name of Designer: <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name CST# <br /> iv 9/.i7 E PRO J Cc <br /> CST's ADDRESS(Street,City,Slate,Zip Code) Phone Number: <br /> oC.T . 2 �O CA-TJ'- a`l d3C% 71 'f Z��l 3J2 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee Groundwater Date ssum gen[STg a re(No Stamps) <br /> Approved ❑ Owner Given InitialJ560 W cNoSurcharge Fee <br /> Adverse Determination <br /> X. COMMENTS/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION. Ongnal to County,One Copy To:Bureau of Plumbing,Owner,Plumber <br />