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DILHR SANITARY PERMIT APPLICATION COUNT <br /> In accord with ILHR 83.05,Wis.Adm.Code <br /> STATE SANITARY P MIT# <br /> a0 ifvq <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBER <br /> 81/2 x 11 inches in size. <br /> —See reverse side for instructions for completing this application. PETITION <br /> 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES ❑ NO <br /> PROPERTY OWNER LPROPERTYOCATION <br /> /a, S T , N, R E (OrPROPERTY OWNER'S MAILING ADDRESS BLOCK NUMBER SUBDIVISION NAME <br /> u) 5�uqINcs Ruc s�raz�CITY,STATE ZIPCODE PHONENUMBER � NEAREST ROAD,LAKE OR LANDMARK <br /> : C n� <br /> II. TYPE OF 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. L^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. See a e Bed b. ❑Seepage Trench c. ❑ seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 15.SYSTEM ELEVATION 6. WATER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED/(Sq are Feet): n(/ r v <br /> / <br /> Y/ { ! — Feet Xprivate ❑Joint ❑ Public <br /> CAPACITY <br /> VI. TANK Site <br /> in gallons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank r ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ I Li I Lj I Ll ❑ <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): Plumb gna e:(N St ps) MP/MPRSW No.: Business Phone Number: <br /> N �� D �. r 3o7a- 7�S 3 '0 <br /> Plumber's Address(Street,City,State,Zip Code: Name of Designer: <br /> leT -3 80 70 / l qtr/ 8 a <br /> VIII. SOIL TEST INFORMATION <br /> CertifiedS Tester(CST)Name CST# <br /> hofJ ! 7 E r7v2o bJ <br /> CST's ADDRESS(Street,City,State,Zip Code) Phone Number: <br /> RT 3 rb S 3 7/ S- -EYL3So <br /> X.COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee Groundwater ate Issuin gent Signature(No Stamps) <br /> Approved ❑ Owner Given Initial rc�hacrgefFJe�e <br /> Adverse Determination 60 6o MS. <br /> �'� <br /> X. COMMENTS/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)IF 03/86) DISTRIBUTION: Original to County,One Copy To.Bureau of Plumbing,Owner,Plumber <br />