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DILHR SANITARY PERMIT APPLICATION COUNTY <br /> �QfIn 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'%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 LPROPERTYOCATIONif n sy --er' F%, S A/ T'3/P, N, R 8(o WPROPERTY O NER'S MAILING ADDRESS BLOCK NU1,11BER SUBDIVISIN NAME <br /> CITY,STATE P S. 5 OOD�E PHONE NUMBER 0 CITY : W�/,V/-RN NEAREST ROSAD,LAK OR L��M�K <br /> In <br /> II. TYPE OF BUILDING OR USE SERVED: f• /' <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.C�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. Q9Conventional 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. 5bSeepage Bed b. ❑Seepage Trench c. ❑ Seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 15.SYSTEM ELEVATION 6. WATER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): /}[� <br /> q/ ri 417"^ 7 ` S Feet Private ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> iin 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 Holding Tank 7 C.. ❑ 1:1 11 <br /> Lift Pump Tank/Siphon Chamber LJ I LJ Ll El El ❑ <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): Plum4aq Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> ROdt� F o k(;,� oa o S' .s �6 <br /> Plumber's Address(Street,Ci ,State,Zip Code): Name of Designer: <br /> W il <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name CST# <br /> p � �. �� StiSeN x(06 � <br /> CST's ALRI SS(Street,City,State,Zip Code) Phone Number: <br /> P (D ogo- L _*_"' <br /> 3 oa k' <br /> r �s 68_r <br /> ENT US b`9S <br /> IX. COUNTY/DEPA TMONLY <br /> I\-'ciI/ ❑ Disapproved Sanitary Permit Fee Groundwater ate Issuin Agent ignature(No Stamps) <br /> LC{,A roved Surpharge Fee <br /> � App ❑ Owner Given Initial R �A'7\ �{ —/71 <br /> Adverse Determination �n U �ZV U Of J <br /> X. COMMENTS/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.03/86) DISTRII3UTIONOriginal to County,One Copy To:Bureau of Plumbing,Owner,Plumber <br />