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DILH17 "R SANITARY PERMIT APPLICATION Do TY <br /> In accord with ILHR 83.05,Wis. Adm. Code <br /> s STATE SANITAR 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. <br /> PETITION <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑VES ❑ No <br /> PROPERTY WNEL. PROPERTY LOCATION <br /> rW'/4 A! %, S Iq T - N, FIS`ak(or) W <br /> PROPERTY OWNER'sAI aNGG ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVIS7 NAME <br /> �] S A <br /> CITY, T TEAry� "n ZIP CODE PHONE NUMBER CITY NEAR ST ROAD,LAKE OR LANDMARK <br /> ❑ VILLAGE: <br /> a G <br /> It. TYPE81F BUILDING OR aedR D: <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. ❑ 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. 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. 19 Seepage Bed b. ❑Seepage Trench c. ❑ Seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPO,,SED(Square Feet): <br /> L ``7� F� Feet ®Private []joint ❑ Public <br /> VI. TANK CAPACITY ED <br /> in <br /> 11 ns Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Steel glass Plastic A <br /> Tanks Tanks <br /> stPp' <br /> Se tic Tank or HoldingTank 7Sa ❑ ❑ <br /> Lift Pum Tank/Siphon Chamber ❑ D ❑ ❑ ❑ <br /> VII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plans. <br /> PI mber's Name(Print): PI is ignature:( o Stamps) MP/MPRSW No.: Business Phone Number: <br /> Plumber' Address(Street,City State,Zip Code): Name of Desi ner: <br /> i -. r <br /> VIII. SOIL TEST INFORMATION <br /> Ce 'ied S it Tester(CST)N e r+� CST# � <br /> CST's AD R SS(Str et,City,S ate,Zi ode) Phone Number: <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee Groundwater ate, Issuin nt Signalur Stamps) <br /> Approved ❑ Owner Given Initial nu aj'� U IonS charge Fee <br /> on � �y_r� <br /> Adverse Determinatie llV X. COMMENTS/REASONS FOR DISAPPROVAL: cC <br /> SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Or,glnal to County,One Copy To:Bureau of Plumbing,Owner,Plumber <br />