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7DILHR SANITARY PERMIT APPLICATION GG TY <br /> In accord with ILHR 83.05,Wis. Adm. Code r <br /> STATE SANITARY PERMIT# <br /> IO <br /> -Attach complete plans(to the county copy only)for the system, on paper not less than STATE PLAN I.D.NUMBER <br /> 8'Fl x 11 inches in size. <br /> -See reverse side for instructions for completing this application. <br /> PETITION <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑ves ❑ No <br /> P PERT/YOWNER 7 PROPERTY LOCATION <br /> c N 4 4 �-e r S /4 /14) '14, SLP T 3f, N, R / it(or ryy <br /> PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBERLNEA2F <br /> VISION NAME <br /> CITY,STATE f 3 ZIP CODE PHONE NUMBER CITY ST BROAD,LAKE ORLNDMARK <br /> L SV 1 VILLAGE: W �/t/•II. TYPE F BUILDING 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. V 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. W 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. ❑ seeDacte Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet):V q1 Q ,p <br /> �. ( •D Feet �q Private ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in <br /> 11 ns Total ##of Manufacturer's Name Prefab. Con- Steel Fiber- plastic Exper. <br /> INFORMATION New xisting Gallons Tanks Concrete glass App. <br /> Tanks Tanks structed <br /> Septic Tank or Holdina Tank -%-o r-Xt C <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ <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 's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> pQ 4 erlc 030S � !J - f <br /> 1Plumber's Address(Street,Citf,State,Zip Code): Name of Designer: <br /> VIII. SOIL TEST INFORMATION tl <br /> Certif dSoil Tester(CS Nam CST# <br /> CST's ADDRESS(Street,City,State,Zip ode) Phone Number: <br /> JI S' <br /> JX4 COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved S nary Permit Fee Groundwater ate Iss g A nt Signature( t ps) <br /> Approved ❑ Owner Given Initial 7((�In) 1�c��lr,; S rcharge Fee <br /> �J <br /> Adverse Determination "`�- "`-' aszn I ��` <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 />