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SANITARY PERMIT APPLICATION C NTY <br /> DILHR In accord with ILHR 83.05,Wis. Adm. Code u r <br /> ST TE SANITARY PE MIT# <br /> 0O- 35 I5 <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than ST TE PLAN I.D.NU BER <br /> 8'h x 11 inches in size. <br /> —See reverse side for instructions for completing this application. PE-ITION <br /> 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FC I VARIANCE ❑YES ❑ NO <br /> PROPERT D E I PROPERTY LOCATION <br /> . I t- r d u r� IU /4 - %, S 7 T 7v, N, R !V(or) W <br /> PS PERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBERLNEAREST <br /> N NAME <br /> ISS 3C )CITY,STATZIP COpDE PHONE NUMpBER CITY A ,L KE ORLANDMARK�2 �S I`t t- LA) S` C 3 /SD -�/S VILLAGE <br /> II. TYPE OF BUILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family C91 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. 9 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. FX1 seepage Bed b. ❑Seepage Trench c. ❑ Seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. W TER SUPPLY: <br /> (Min')tes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): <br /> 7.1 •/''J <br /> Feet FPrivate ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in all in Total #of jPrefab. Fiber- Exper. <br /> INFORMATION New xisting Gallons Tanks Manufacturer's Name rete Con- Ste glass Plastic App <br /> Tanks Tanks strutted <br /> I- <br /> Septic Tank or HoldingTank '1SV ) 1,1 t ❑ <br /> Lift Pum Tank/Siphon 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(Print):��ii Plluury hr's Signature: No Stamps) MP/MPRSW No.: Business Phones Number: <br /> rl <br /> Ry I 4Z 3 0 3 / a�G'A 7�.�,. <br /> Plumber's Address(Street,Ci ,State,Zip Code): Name of Designer: <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soi Tester(CST)Ne C <br /> ST o e i 0 k - 7 <br /> CST's ADDRESS(S eet,City,State,Zip ode) rw � P6G - yi S' <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee Groundwater ate I Agent Si ure(No Stamps) <br /> Approved ❑ Owner Given Initial Surcharge/F;eee <br /> Adverse Determination as' `"' 4 <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 />