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n SANITARY PERMIT APPLICATION <br /> 01LHR In accord with ILHR 83.05,Wis.Adm.Code <br /> STATE SANITARY ERMIT# <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBER <br /> 8'/2 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 /> P RTY OWNER -7-' ]PLROPERTYIONC4o1' nldr-sTr^7 L6 a, S T YD, N, R Ito &(or) W <br /> P RTY OWNER'S MAILING ADDPRE�s BLOCK NXBER SUBDIVII ION NAMEd / 3 /�{r •e l� Al—ft QJ'= Rxvr� 1011,Irr <br /> CITY,STATE ZIPCODE PHONE NUMBER / NEARESTRO D LAKEORLANDMARK <br /> l!K O �.�� W U -e r <br /> II. TYPE OF BUILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family a 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. DO Seepage Bed b. ❑ Seepage Trench C. ❑ See a e Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: <br /> (Minutes per inch): REOUI D(Square Feet): PROPOSED(Square Feet): <br /> 3 Feet Private ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- LExper.INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass PlasticTanks Tanks struttedSe ticTank or Holdin Tank ` <br /> Lift Pum Tank/Si hon Chamber ❑ I ❑ ❑ <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' <br /> Print): Plu 's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> o l Ic o i� 63es'9 7is YAW- Wr7 <br /> Plumber's dress(Street,City,Slate,Zip Code): Name of Designer: <br /> VIII. SOIL TEST INFORMATION <br /> Cer[ifjad Soil ester(qST)Name CST# el.3 <br /> ,ALJ h C <br /> CST's ADDRPrSS�t,Chitty,State,Zip de Phone Number: <br /> W /O c3-r/ 4,./S <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved I Sanitary Permit Fee I Groundwater ate ]as A nt Signature Stamps) <br /> Approved ❑ Owner Given Initial ' /�n.AV-) Sure Fee <br /> Adverse Determination �f Lki ',Vq}V, <br /> X. COMMENTS/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-87)(R.03/86) DISTRIBUTION: O:igmal to County,One Copy To:Bureau of Plumbing,Owner,Plumber <br />