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DILHR SANITARY PERMIT APPLICATION CO Y <br /> (ZIIn accord with ILHR 83.05,Wis. Adm. Code <br /> ST TE SANITARYP RM��IT# <br /> YIqW53 <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ST TE PLAN I. 13 <br /> 8%x 11 inches in size. <br /> -See reverse side for instructions for completing this application. PE (TION <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. FOI I VARIANCE ❑YES ❑ NO <br /> PROPERTY OWNER PROPERTY LOCATION <br /> C irk-rC -erne 4 a Sw ''/4Sw %4, S Q T Vd, N, R '/ OR (or) W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISI N NAME <br /> 3io S , rsoW [au-e .V <br /> Y,,STATE ZIP CODE PHONE NUMBER CITY NEAREST AD,LAKE OR LANDMARK <br /> 1V J F J S W ^yd1.1. 74r S- llt Q VILLAGE ' ft h iO N D Y �4, <br /> II. 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. M 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 Agreeme it 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. [Y�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): REOUIIRED(Square Feet): PROPOSED(Square Feet): <br /> Y, r[ S t -7 (o 2- 17 C�! <br /> .4 Feet ©P ivate ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in allonsTotal #of Prefab. Fiber- Exper <br /> INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Stee glass Plastic App. <br /> Tanks Tanks strutted <br /> Se tic Tank or Holding Tank )c 1 W �r ® ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber 1 ❑ <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): Plumber's�Signature* <br /> (No Stamps) MP/MPRSW No.: Bu mass Phone Number: <br /> rt c !A 6,31 O S <br /> Plumber' Address(Street,City,State,Zip Code): Name of Designer: <br /> u-,- I - s9FjP � s <br /> VIII. SOIL TEST INFORMATION <br /> Ce ,ed S it Tester(CST)Name CST# <br /> Q• `E,(`L C 12 S <br /> CST's ADDRESS(Street,City,State,Zi Code) Phone Numb r: <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee I Groundwater ate I in Agent Si ure(No Stamps) <br /> Approved ❑ Owner Given Initial Q'(� Surcharge Fee <br /> ��,{}1I. <br /> Adverse Determination `ii "U`n / <br /> X. COMMENTS/REASONS FOR DISAPPROVAL: <br /> L_____ — - <br /> SBD-6398(fo,merry Plb-67)IF 03/86) DISTRIBUTIONS ^rgmal to County,One Copy To:Bureau of Plumbing,Owner,Plumber <br />