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_ s SANITARY PERMIT APPLICATION D rDiLHR In accord with ILHR 83.05,Wis. Adm. Code STATE SANITARY P MIT# <br /> 13 � <br /> —Attach complete plans (to the county copy only)for the system,on paper not less than S1 ER <br /> 8'%x 11 inches in size. <br /> —See reverse side for instructions for completing this application. P TITION <br /> 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. F R VARIANCE ❑YES ❑ NO <br /> PROPERTYOWNER PROPERTY LOCATION '/ <br /> ler-e/e!l e. OenOh`er 5,5 '/a �E '/a, S Y TS, , N, R E (or)�o <br /> PROPERTY OWNER'S MAILING ADDRESS LOTNUMBER BLOCKNUMBER S <br /> 16, '1 A&Y vlv — 16bled avV hof Y� <br /> CITY__,LSTATE_ <br /> JA <br /> // ZI <br /> P <br /> /90DJE PHONE NUM�BI�_5 71 rye CITY %AREST OAD,/LAKE ORLLANDMAR <br /> �A/�UJ7C/ 17t7r ,s P93 �/J '3Y7T OBJ VILLAGE:Za- o <br /> II. TYPE OF BUILDING OR USE SERVED: LL ----// <br /> Number of Bedrooms if 1 or 2 Family � 46tr�00/YLS 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 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.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP <br /> In-Fill Tank <br /> V. ABSORPTION SYSTEM INFORMATION: (Check one) <br /> 1. a. 9Seepage Bed b. ❑ Seepage Trench c. ❑ Seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 75.SYS7TEM—;ELEVATION 6. TER SUPPLY: <br /> (Minutes er inch): REQUIRED(Square Feet): PROPOSED( quare Feet) r}y(Feet Ix11 rivate ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in gallons Total #of Manufacturer's Name Prefab. Con- St I Fiber- plastic App. <br /> Expp. <br /> INFORMATION New xisting Gallons Tanks Concrete glass <br /> Tanks Tanks strutted <br /> Septic Tank or Holdin Tank Iso — 'fS� �y^� ❑ ❑ E-1Lift Pum Tank/Si hon Chamber ❑ ❑ L-1 <br /> VII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plan . <br /> Plumber's Name(Print): Plumber's Signature:(No Stamps) MP/MPRSW No.: B isiness Phone Number: <br /> ,Alode &;SAO/m 33Ca1 7/s P&, - <br /> Plumber's Address(Street,City,State,Zip Code): Name of Designer: <br /> aloha 7W I,</e,651ci, 14/1 svF9,3 L410de, 4AjA1)1 <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name CST# <br /> Qde ,Qu�shr�lm <br /> CST's ADDRESS(Street,City,State,Zip Code) Phone Num er: <br /> Same 7/s P(o!o- 7aPlP <br /> 14. COUNTY/DEPARTMENT USE ONLY <br /> PP <br /> 71 Disapproved Sary Permit Fee Groundwater ale Is ing gent ignat o Stamps) <br /> ,jj(JJ� r�.,�j Surd e F / �O <br /> roved ❑ Owner Given Initial A <br /> ee <br /> Adverse Determination <br /> X. COMMENTS/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumb <br />