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DILHR SANITARY PERMIT APPLICATION COUNTY <br /> _ In accord with ILHR 83.05,Wis.Adm. Code r <br /> ' S TE SANITARY P (;RMIT# <br /> TC <br /> –Attach complete plans(to the county copy only)for the system,on paper not less than ST ATE PLAN 1.D.NUMBER <br /> 8'%x 11 inches in size. <br /> –See reverse side for instructions for completing this application. PE TITION <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. F R VARIANCE ❑YES ❑ NO <br /> PROPERTYOWNER �i PROPERTY LOCATION <br /> b0 It6%( arIT p4 SW Y, A; Ya, S a7 TYl , N, R filo 4(or)W <br /> PR PERTY OWNER'S MAILING RESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME <br /> 4 u4 Pik <br /> CITY,STATE 21P CODEPHONENUMBER CITY NEAREST CAD,LAKE OR LANDMARK <br /> �,S,O� ❑ VILLAGE :rV TOWN OF: S' ; S S LCI N C h'P C <br /> It. TYPE O UILDING 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. LCI 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. A Conventional 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. Y Seepage Bed b. ❑Seepage Trench c. ❑ seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. W TER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): <br /> Q /p 1ct 1. Feet I�`� ivate ❑Joint ❑ Public <br /> CAPACITY Site <br /> VI. TANK in allons Total #of Manufacturer's Name Prefab. Con- Steil Fiber- plastic Exper. <br /> INFORMATION New xisting Gallons Tanks Concrete glass App. <br /> Tanks Tanks structed <br /> Septic Tank or Holdino Tank X I 7S0 I 'T C Ej ❑ <br /> Lift Pump Tank/Siphon Chamber /fit C ❑ ❑ ❑ <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): Plu r S' nature:( o Stamps) MP/MPRSW No.: BL siness Phone Number: <br /> tvtc r �� l7sp 7IS fd'YIJ-7 <br /> lumber's dre (reel, i ,State``,Zip Code): Name of Design \ <br /> Al M <br /> Vlll. SOIL TEST INFORMATION <br /> Cer W ied S it Test\(CST)Name CST# <br /> ntc d <br /> CS 'sem DR ESS Street,City,State, Code) Phone Number: /� <br /> 1/D i vuPtj/J G <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> rl� ❑ Disapproved Sanitary Permit Fee Groundwater ate Issu' gent Si pure(No Stamps) <br /> Lpl Approved F-1OwnerGiven Initial Surcharge Fee 1 <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 />