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DILHR SANITARY PERMIT APPLICATION CCUn'y j- <br /> In accord with ILHR 83.05,Wis.Adm. Code �'11 r '�'�\'` <br /> ST TESANITARYPERMIT# � <br /> -Attach complete plans (to the county copy only)for the system, on paper not less than ST kTE PLAN I.D.NUMBER <br /> 8'h x 11 inches in size. <br /> -See reverse side for instructions for completing this application. PE ITION <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. Fo VARIANCE ❑YES ❑ NO <br /> PROPERTY OWNER PROPERTY LOCATION <br /> G So A) S-6 '/a, S o�,7 T yU, N, R r IP(or)W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOC NUgBER SUBDAIVtISI N NAME <br /> 0 r $ c A (C Q k) rV <br /> CITY,STATE ZIP CODE PHONE NUMBERCITY .}- NEAREST CAD a�AKE OR LAND ARK <br /> C O O VILLAGEOWNOF: Jq C 5�Aj r_/!� <br /> I S <br /> 11. TYPE F 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. �N 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 AgreelmE nt 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 f. IGP <br /> In-Fill Tank <br /> V. ABSORPTION SYSTEM INFORMATION: (Check one) <br /> 1. a. Seepage Bed b. ❑Seepage Trench c. ❑ Seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 15.SYSTEM ELEVATION 6. WATER SUPPLY: <br /> (Minut s per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): Imo, <br /> 4//() `T / s—Feet RP ivate ❑Joint ❑ Public <br /> VI. TANK CAPACITY Ls <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New ns <br /> Gallons Tanks Manufacturer's Name ConcreteSte glass Plastic App <br /> Tanks Tanks <br /> Septic Tank or HoldingTank M ❑ L. ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ 1 11 1 ❑ <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 <br /> /fame(Print): Plumber's Signature:IJINo Stamps) A MP/MPRSW No.: Bu 5iness Phone Number: <br /> 71s- ) bo, f,/-5,7 <br /> Plumber's Address(Street,City!State,Zip Code): ro Na ofigner: I <br /> �J <br /> VIII. SOIL TEST INFORMATION <br /> Ced S 'I Tester(CST)Name 10 CST# <br /> t � <br /> CS 's ADD SS(SUeeet,t,City,State, ip Cod Phone Number <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee Groundwater ate Issu gent Si)natu oStamps) <br /> Approved ❑ Owner Given Initial Surcharge Fee <br /> ��i1. r�ry3 <br /> Adverse Determination <br /> X. COMMENTS/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: One nal to County,One Copy To:Bureau of Plumbing,Owner,Plumber <br />