Laserfiche WebLink
SANITARY PERMIT APPLICATION CDNyps+�y, <br /> 4 DILHR In accord with ILHR 83.05,Wis. Adm. Code '� j <br /> STATE SANITARY PERMIT# <br /> I <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than ST TE PLAN I. UMBER <br /> 8'h x 11 inches in size. <br /> —See reverse side for instructions for completing this application. PE ITION <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FO VARIANCE ❑YES ❑ NO <br /> PROPERTY OWNER PROPERTY LOCATION <br /> S. o Cv r` oe A S1E '/4 /4, S l3 0, N, R E (orW <br /> PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NU BERLNEAREST <br /> N NAME rte 0i <br /> D w 4u I /U CITY,/gTA7 ZIP CODE PHONE NUMBER CITY AD,LAKE ORLANDMARK <br /> 5 dFref ��E �I.�7 VOtJ <br /> cCd T <br /> If. TYPE OF BUILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family 23 OR ❑ Public(Specify): <br /> III. PURPOSE OF APPLICATION: (Check only one in#t 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. M 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 AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. W TER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(quare Feet):l!D 0 <br /> O -A -7 Feet 5 P ivate ❑Joint ❑ Public <br /> VI. TANK CAPACITYiIn allons Total #of Prefab. Site Fiber- Exper. <br /> INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Ste I glass Plastic App <br /> Tanks Tanks structed <br /> Se tic Tankor Holdin Tank (AlC. ❑ ❑ <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): E4ltnber's Signal :(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> 61 C h Tsar 1 (�)4 t � 0 �1 1 `� <br /> PI u m be CA Address(Street, Ity,State,Zip Code): Name of Desi In <br /> C <br /> VIII. SOIL TEST INFORMATION <br /> Cer' 'ed I Tester(C I Name C CST# Z <br /> � _V/ �rrc <br /> CST's ADD E ( treat,City,State,Zip ode) Phone Number: <br /> t �s� ' S , s F� 3 ��7 - lJ <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved I Say itary Permit Fee Groundwater uing gent Si n r (No Stamps) <br /> Approved ❑ Owner Given Initial (�'y�� rcharga Fee <br /> Adverse Determination *"" ' � U <br /> X. COMMENTS/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTIONOriginal to County,One Copy To:Bureau of Plumbing,Owner,Plumber <br />