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DILHR SANITARY PERMIT APPLICATION D 'TYu <br /> In accord with ILHR 83.05,Wis. Adm. Code ST TE SANITARY PERMIT If <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than _S_l ATE PLAN I.D.NUMBER <br /> 8'h 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. FOR VARIANCE ❑VES ❑ NO <br /> PRO PITY OWNER LLiT�N <br /> CATION // <br /> Z L 4 6 41 Ya, S 3 T f7, N, R Y ! (or).W <br /> PROP YOV�ER'S MAILING ADDRESS BLOCK F UJ.4BER SUBDIVISI NNAME <br /> 'T Orli �l//A'*' N <br /> CITY,STATE ZIP CODE PHONE NUMBER 'j� NEAREST OADAAL,��AKE OR 4ANDMAR/K <br /> ` r S'Cv 't / •ii/C (hSr-e 4Q <br /> 11. TYPE OF BUILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family 2 OR ❑ Public(Specify): <br /> III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) <br /> 1. a. N New b. ❑ Replacement c. ❑ Replacement of d.❑ Reconnection of e.E1 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. ®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. 50 Seepage Bed b. ❑See a e Trench c. ❑ Seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 14. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): <br /> /Q i_ T7 'F Feet ICV' rivate El joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in allc Total III of Prefab. Fiber- Exper. <br /> INFORMATION New xiss Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdino Tank 7Sd SoIf <br /> Li <br /> Lift Pump Tank/Siphon Chamber I Ll I L I ❑ ❑ ❑ <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:(N Stamps) MP/MPRSW No.: B isiness Phone Number: <br /> O `c c <br /> Plumber's Address(Street,City',Slate,Zip Code): Napo er: <br /> W S` �� <br /> VIII. SOIL TEST INFORMATION <br /> Cert;Afd Soti Tester(CST)Name CST 11 <br /> rh tl -f N <br /> CS ADDR S( eL City, tate,Zip ode) Phone Num er: <br /> Q <br /> c_l '71 F - !r1l <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved I S nitary Permit Fee I Groundwater ale Issuin nt ignat No Stamps) <br /> pproved ❑ Owner Given Initial (/ry^) Sur�c-'lh1arge Fee <br /> Adverse Determination ""' (�o <br /> X. COMMENTS/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)IF 031861 DISTRIBUTION: Original to County,Ore Copy To:Bureau of Plumbing,Owner,Plumber <br />