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DILHR SANITARY PERMIT APPLICATION ° D {�u�ne <br /> In accord with ILHR 83.05,Wis.Adm.Code S TESANITARY ERMIT# - <br /> 3 <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D. BER <br /> 8'%x 11 inches in size. <br /> —See reverse side for instructions for completing this application. PE TITION <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES ❑ NO <br /> PROPERTY OWNER / PROPERTY LOCATION <br /> EC y}�f}N ('E '/4 SE Y4, S T , N, R ^ E (or W <br /> PROPERTYOWNEFU MAILINGADORESS LOTNUMBER BLOCKNUMBER SUBDIVISI)NNAME <br /> 6639 TH�Rn qvE so, R/cNFi v.s 99 is.- 9,DD, S&-ZW .cam /30eL-� <br /> CITY,STATE ZIP CODE PHONE NUMBER Ll CITY NEAREST IOAD,baa OR LANDMARK <br /> VILLAGE ; SGc7L B yi7-6/f1'z/EL.9 <br /> It. 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. ew b. ElReplacement c. ElReplacement of d. ❑ Reconnection of e ❑ Repair of an <br /> ystem 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 Agreent4int to County Copy. <br /> IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2) <br /> 1. a.ElConventional 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. D41seepage Bed b. ❑Seepage Trench c. ❑ Seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. W kTER SUPPLY: <br /> (Minutes per inch): REQUIRED <br /> /(Square Feet): PROPOSED(Square Feet): (cyl <br /> `Z'/ ld�-9 Feet 1/� rivate ❑Joint El Public <br /> VI. TANK CAPACITYin galions Total #of Prefab. Site 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 Holding Tank 73-0 76-0 / %•• W,el <br /> Lift Pump Tank/Siphon Chamber I I Li Li <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): 1�57 <br /> natur� (No Stamps MPIMPRSW No.: B siness Phone Number: <br /> uR//� c • tW0rt T [�C � 30°72 71S o�4�/ vScs <br /> Plumber's Address(Street,City,State,Zip Code): Name of Designer: <br /> T 1ZF 30 Z/7o <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name CST# <br /> ,,i Q l r= <br /> CST's ADDRESS(Street,City,State,Zip Code) Phone Number <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved I Sanitary Permit Fee Groundwater ate Issuing gent Si nature(No Stamps) <br /> CU <br /> Approved ❑ Owner Given Initial /G-,(,�� 00 S rcharg//e�rF�e,e <br /> Adverse Determination `'�""' �rJ•w Fl� <br /> X. COMMENTS/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Pib-67)IF 03/86) DISTRIBUTIONS Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber <br />