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DILHR SANITARY PERMIT APPLICATION G TYr <br /> In accord with ILHR 83.05,Wis.Adm. Code S TESANITARY ERMIT# <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than STToE PLAN I.D.NUMBER <br /> 8'/i x 11 inches in size. O? 31 bw <br /> -See reverse side for instructions for completing this application. PE ITION <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. F VARIANCE ❑YES O <br /> PROPERTY OWNER PROPERTY LOCATION <br /> I� �v 4 R n �i c '/n A/w '/s, S [IF T d, N, R 6 E (or)W <br /> -r- <br /> d f- / <br /> PROPERTY OWNER'S MAILING AEJDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NA E <br /> ,B o ! P N �ilur i` <br /> CITU,STATE ZIP CODE PHONE NUMBER CITY /./ 1 NEAREST OAD,LAKpO LANDMARK <br /> dl'tiC s-dv_4 MM TOWN OF <br /> VILLAGE : <br /> H. TYPE 00 BUILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family �' OR ❑ Public(Specify): <br /> Ill. 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 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. *Conventional b.2� Alternative c. ❑ Experimental <br /> 2. a. ❑System- ,;rt)M tMding. c.El 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. ❑ Seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 14. ABSORPTION AREA 5.SY=Feet <br /> TER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): <br /> rivate El Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New Existing Gallons Tanks Manufacturer's Name Concrete strr cted Ste 1 glass Plastic App <br /> Tanks Tanks <br /> Septic Tank or Holdin Tank OQo ( �- Ll <br /> Lift Pum Tank/Siphon Chamber Ll <br /> VII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plan . <br /> Plumber's Name(Print): Plu is signaatur No Stamps) MP/MPRSW No.: B siness Phone Number: <br /> v ric o %Lr cr, `L 6301' /,s— !S <br /> Plumber's Address(street,City,State,Zip Code): Name of Designer: <br /> W`e b T r ,s <br /> VIII. SOIL TEST INFORMA ION- <br /> Cered S it Tester(CST)Name CST# <br /> 1� `l O C�I S <br /> CST's ADDRESS(Street,City,State,Zip de) Phone Number: <br /> 0 IS- 8006 - «7 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sa nary Permit Fee Groundwater ate Is ent gnat (No Stamps) <br /> Approved ❑ Owner Given Initial �Xjr/k' (�� S charge(Fee <br /> � �/'(� /N�. <br /> Adverse Determination vv ' "" �5'"— " '—' `_� <br /> X. COMMENTS/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumbe <br />