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DILHR SANITARY PERMIT APPLICATION C NTY <br /> In accord with ILHR 83.05,Wis. Adm. Code ST TE SANITARY ERMIT# <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than ST NTE 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. FC R VARIANCE ❑YES ❑ NO <br /> PROPERTY OWNER PROPERTY LOCATION <br /> Fa Lir .S-2 9 s . nr UE '/s A.tw '/., S /P T -'/o , N, R b e(or) W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAM <br /> � � X 131 r7 /v A A" Rt z <br /> CITY,STATE ZIP CODE PHONE NUMBER CITY NEAREST OAD,LAKE OR LANDMARK <br /> ( �rl S So3 VILLAGE : ba lr4s* /� <br /> c rC <br /> It. TYPE 00 BUILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family OR ❑ Public(Specify): <br /> Ill. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) <br /> 1. a. 4 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 Agreem 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.11 Pit Privy d. ❑ Vault Privy e. ❑ Mound f. IGP <br /> In-Fill Tank <br /> V. ABSORPTION SYSTEM INFORMATION: (Check one) <br /> 1. a. X 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 /> a-- 1410 3 7-, /Q <br /> 6' 7 Feet CXJ ivate ❑Joint ❑ Public <br /> VI. TANK CAPACITYn allons Total #of Prefab. Site Fiber- Exper. <br /> INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Ste I glass Plastic App <br /> Tanks Tanks structed <br /> Septic Tank or Holding Tank �S'UL_H �C <br /> Lift Pum Tank/Si hon Chamber ❑ 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): Plum is Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> a 3 Qs- s D(off-y�s7 <br /> Plumber's Address(Street,City,State,Zip Code): Name of Desi er: <br /> VIII. SOIL TEST INFORMATION <br /> Car ied SPiI Tester(CST)Name ,�--. CST# �� <br /> lC cVE C CS /l C!t S <br /> CST's ADDRESS(Street,City,Stale,Zip Code) Phone Numb r. <br /> 866 [s <br /> IX. .000NTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved I Sanitary Permit Fee Groundwater ate Iss n Agent Sint e(No Stamps) <br /> proved ❑ Owner Given Initial �}{ Ari S charge F/e�ef� <br /> Adverse Determination `Mr l..�Jp�5'"`-' <br /> X. COMMENTS/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Pib-67)in,03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber <br />