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OILHR SANITARY PERMIT APPLICATION COUNTY <br /> _ In accord with ILHR 83.05,Wis.Adm. Code —Luirinett <br /> ST NTE SANITARY PERMIT# <br /> 5 l�' <br /> —Attach complete plans(to the county copy only)for the system, on paper not less than s TE PLAN I.D.NUMBER <br /> 8'/z x 11 inches in size. <br /> —See reverse side for instructions for completing this application. PETITION <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FCR VARIANCE ❑YES ❑ NO <br /> PROPERTY OWNER PROPERTY LOCATION <br /> err. tk 'b RcvM SE % vE %, S 7 T O, N, R &(or)W n <br /> PR PERTV OWNER'S MAILING DRESS LOT NI) BER BL HUMBER �4BDNI$ION fNAME U'e� PtotCS <br /> Cl Y,STATE ZIPCODE PHONE NUMBER 0U CITY VILLAGE : ri- NEAREST ROAD,LAKE OAR ARK <br /> lhl 1 O r) <br /> Il. TYPE OF13UILDING 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. ® 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 AgreemE nt to County Copy. <br /> IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2) <br /> 1. a. 19 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. ®Seepage Bed b. ❑Seepage Trench c. ❑ Seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. W TER SUPPLY: <br /> (Minutes per inch): REOULI R' V Feet ED(Square Feet): PROPOSED(Square Feet): <br /> 7 � 3 �. ��'� �P Nate ❑ ❑ <br /> Joint Public <br /> VI. TANK CAPACITY Site <br /> in allons Total #of Manufacturer's Name Prefab. Con- Ste I Fiber- Plastic Exper. <br /> INFORMATION New xisting Gallons Tanks Concrete glass App. <br /> Tanks Tanks structed <br /> Septic Tank or Holding Tank SO ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ 1 Lj ❑ <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.: Bu iness Phone Number: <br /> LA V <br /> ply 1�r-eU (�j�i �2 0 o S 9 <br /> Plumber's Address(Street,City,State,Zip Cod r Name of Designer: <br /> l,.!•-c 6I T r W j I . s-- 9 <br /> VIII. SOIL TEST INFORMATION <br /> Cefied S°J I Tesler(FST)Name CST# <br /> C) derLt C /it f l 7 <br /> CST's ADDRggSS(Street,City,State,Zip Code) Phone Number: <br /> . S g f �1 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee Groundwater ate Issu g A nt Si natur Stamps) <br /> Approved ❑ Owner Given Initial mat fpm Surcharge <br /> Fee 1� <br /> Adverse Determination W '*'�'�'on <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,Plumber <br />