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DILHR 1777- SANITARY PERMIT APPLICATION COUNTY <br /> In accord with ILHR 83.05,Wis. Adm. Code <br /> STATE SANITARY 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'/z 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 /> Neil Miller GL8 %a /4, S25 T 38 , N, R 18 x9Xor) W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME <br /> Rt.l Box 1623 3 na na <br /> CITY,STATE ZIP CODE PHONE NUMBER CITY NEAREST ROAD,LAKE OR LANDMARK <br /> Hudson, WI 54016 VILLAGE :Wood River Little Wood Lake <br /> I1. TYPE OF BUILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family 2 OR ❑ Public (Specify): <br /> Ill. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) <br /> 1. a. x❑ 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. ❑Alternative C. ❑ Experimental <br /> 2. a. ❑System- b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound I. ❑ 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): <br /> 2 410 420 94.00 Feet ©Private El joint El Public <br /> VI. TANK CAPACITY Site <br /> in allons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- plastic Exper. <br /> INFORMATION New xisting Gallons Tanks Concrete glass App. <br /> Tanks Tanks strutted <br /> Septic Tank or Holdin Tank750 ❑ <br /> Lilt Pum Tank/Si hon Chamber ❑ Fj <br /> ❑ ❑ <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): =71,2,7';,� <br /> nature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> Donald Daniels MEW 330 715 349-5533 <br /> Plumber's Address(street,City,State,Zip Code): Name of Designer: <br /> Box W, Siren, WI 54872 Same <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name CST# <br /> Joan Daniels 3431 <br /> CST's ADDRESS(Street,City,State,Zip Code) Phone Number: <br /> Box W, Siren, WI 54872 715 349-5533 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee Groundwater ate Issuing,Agent Signature(No Stamps) <br /> Approved <br /> El Given Initial -� S rcharge Fee ; <br /> Adverse Determination <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,Plumber <br />