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�fLHR SANITARY PERMIT APPLICATION COUNTY <br /> In accord with ILHR 83.05,Wis. Adm. Code F�A f <br /> _STW TESANITARYP RMIT# <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than STi TE PLAN I.D.rqUMBER <br /> 8'h x 11 inches in size. <br /> —See reverse side for instructions for completing this application. PE (TION <br /> 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FO VARIANCE ❑YES ❑ No <br /> PRO E LTYO N PROPERTY LOCATION <br /> �W'/4512 '/a, S T3 N, R E (or <br /> PR RTY OWN R'S MAKING ADDRESS LOT NUM ER BLOCK N MBER SUBDIVISI N NAME <br /> TE ` ZIP CODE PHONE NUMBER CITY NEAREST AD,LAKEOR LANDMARK <br /> / b3,,3 O VILLAGE <br /> R6TSTA <br /> PE OF ILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family OR 11 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 t to County Copy. <br /> IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2) <br /> 1. a. Wconventional b. ❑ Alternative c. ❑ Experimental <br /> 2. a. L1 System- b. ❑ Holding c.L1 Pit Privy d. ❑ Vault Privy e. ❑ Mound I. El IGP <br /> In-Fill Tank <br /> V. ABSORPTION SYSTEM INFORMATION: (Check one) <br /> 1. a. Seepage Bed b. ❑Seepage Trench C. ❑ See a e Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WP TER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): C/ INA <br /> E' �5 �/ /S �! / �' Feet KAP ivate ❑Joint ❑ Public <br /> CAPACITY <br /> VI. TANK Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xisting Gallons Tanks Manufactuler's Name Concrete Con- Stee glass Plastic App <br /> Tanks Tanks � structed <br /> Septic Tank or HoldingTank 6 ❑ I Q I Z5. <br /> ❑ ❑ <br /> Lift Pum Tank/Si hon Chamber ❑ I L I ❑ ❑ ❑ 1 ❑ <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): Plu is Signature:(No tamps) M .. Business Phone Number: <br /> 1-e a l s ys8-p l-iti3 <br /> PfuFbbeV Address(Street,City,State,Zip Codey'. • Name of Design <br /> /,015 1 ? % <br /> Vlll. SOIL TEST INFORMATION <br /> Certified o' ester(CST)N CST# <br /> CST' RESS(Sire t, ity,State,Zlp Code) Phone Numb r: <br /> /66 ,y Y 9 <br /> IX. C UNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sa nary Permit Fee Groundwater ate Issui Agent Si nature(No Stamps) <br /> pproved ❑ Owner Given Initial c` I ,/�"'� Surcharge Fee _ (� , <br /> Adverse Determination �- �((jj W r�S,kf.+yL•J, �J';� LA&,L)C� " rte <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 />