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C� DILHR SANITARY PERMIT APPLICATION COUNT/v/ <br /> In accord with ILHR 83.05,Wis.Adm. Code <br /> STATE SANITARY PERMIT# <br /> 796 7 lizsy <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBER <br /> 8Yz x 11 inches in size. <br /> —See reverse side for instructions for completing this application. PETITION <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES ❑ NO <br /> PROPERTY OWNER PROPERTY LOCATION <br /> � - �, n y /so"Vw '/4TLj , Saf, Tya , N, R (or) W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME <br /> 7,q0o F-re Box 337 <br /> CITY,STATE ZIP CODE PHONE NUMBER CITY NEAREST BROAD,LAKE OR LANDMARK <br /> S OO{/PY .01 5 y ro VILLAGE <br /> H : -Lo77- I -9 I� <br /> II. TYPE OF BUILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family 3 OR ❑ Public(Specify): <br /> 111. 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. 9 seepage Bed b. ❑seepage Trench c. ❑ seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): <br /> G 3 (01Jr 6 /n 1 <br /> Ant 9 y o Feet IN Private ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in allons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. <br /> INFORMATION New xisting Gallons Tanks Concrete glass App. <br /> Tanks Tanks Site <br /> Septic Tank or Holding Tank '� /tl DO f Lo t E P lr C oNo Y ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ <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:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> Gv u/ �qu �SriV � ' � a Ga 51 � 4Sy <br /> Plumber's Address(Street,City,State,Zip Code): Name of Designer: <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name CST# <br /> CSDR <br /> DE S(Street,City,State,Zip Code) Phone Number: <br /> /T'�s A <br /> T. D- o x 7 l S' r,7 oon/,ewT J y4o 1 7i s' G3e— 7J ` 5 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee Groundwater rI7af,_____j Issuing Agent Signature(No Stamps) <br /> p0 Surcharge Fee <br /> Approved ❑ Owner eDetermial `f� / /ice ��� '27_0/ <br /> Adverse Determination ` 6(1 l7 <br /> X. COMMENTS/REASONS FOR DISAPPROVAL: F <br /> SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To.Bureau of Plumbing,Owner,Plumber <br />