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DILHR SANITARY PERMIT APPLICATION COUNTY <br /> In accord with ILHR 83.05,Wis.Adm.Code <br /> STATE SANITA PERMIT# <br /> I J, <br /> -Attatph complete plans (to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBER <br /> 8'/A 111 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 LINO <br /> PR ER YOWNER PROPERTY LOCATION <br /> Q S 00 Pf: % A)W '/4, S 3rT�lJ , N, R IS— E (o W , <br /> PROS OWNERS r7L711N1G ADt LOT%UMBER BLOCKAl NUMBER SUBDIVISIONNAME <br /> C.I/TYY,,5TATE A,- ZIPCODE PHONENUMBER CITY ``LS- NEAREST ROAD,LAKE <br /> /O"R LANDMARK <br /> "�( S'S7D , ` .�ot TOWNOF <br /> VILLAGE : Qc.�SoeJ `TLti (Qlf' <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. ❑ New b.;�4Replacement 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. nConventional b. ❑Alternative C. ❑ Experimental <br /> 2. a. ❑System- b. ❑ Holding 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. W 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): q/ _ <br /> 0 3 )-- 16d Feet yY Private ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdina Tank2 <br /> 3`0 <br /> -", C El 1:1 <br /> Pum Tank/Siphon Chamber ❑ Lj ❑ <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: No Stamps) MP/MPRSW No.: Business Phone Number: <br /> IT0d NSIG J (936 7/-f fa-W-5-7 <br /> Plumber's Address(Street,City,State,Zip Code): Name of Designer: <br /> l..W-+_� S Y 8Q S/jzvnn—` <br /> VIII. SOIL TEST INFORMATION <br /> Certified Sqqd Tester JCST)Name fl CST# <br /> /� (C' LL%r d d [h T 96 ? 0 <br /> CST's AD RESS(Street,City,State,'Zip Code) Phone Number: <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> *I`q)1 ❑ Disapproved Sanitary Permit Fee Groundwater ate Iss gent Signatur 0Stamps) <br /> Approved ❑ Owner Given Initial 100 S h��a e <br /> / \ Adverse Determination 'XJ VU <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 />