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SANITARY PERMIT APPLICATION co TY <br /> In accord with ILHR 83.05,Wis.Adm. Code ✓ <br /> ffq=%n�9 S 1111 ATE SANITARY PERMIT# <br /> a 13Nko <br /> —Attach complete plans(to the county copy only)for the system, on paper not less than STATE PLAN I.D.NUMBER <br /> 8'h x 11 inches in size. <br /> -See reverse side for instructions for completing this application. PETITION <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. I FOR VARIANCE ❑YES ❑ NO <br /> P ERN OW qyy7� LPROPERTYATIONI h 2 0 //O '/a, S oZ T_jV N, R 1- (Or) W <br /> PROPERTY OWNER'S MAILING ADDRESS BLOCKNUMBER SUBDIVIS`ONNAME <br /> 37 s *- W7" -f/ ,v A- �!CITY,STATE ZIP CODE PHONENUMBERNEAREST Rf1AD,LAKE ORLANDMARK <br /> 5�7 /QC o Al 0 / <br /> Tnobiji aJ <br /> II. TYPE OF BUILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Familyd OR ❑ Public(Specify): <br /> III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) <br /> 1. a. PiNz New b. ❑ Replacement c. ElReplacement of d.❑ Reconnection of e.ElRepair 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. 91 See a e Bed b. ❑Seepage Trench c. ❑ Seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet) i PROPOSED(Square Feet): c� r <br /> / �© U r Feet Ja'Private ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or HoldingTank s� 1 e' LJ <br /> Lift Pum Tank/Si hon 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 is Signature: No Stamps) MP/MPRSW No.: Business Phone Number: <br /> C3 ©s 7 s'7 <br /> Plumber's ddress(Street,City,State,Zip Code): Name of Designer: <br /> W U-tA4 S <br /> Vlll. SOIL TEST INFORMATION <br /> C 'ad S it Tester( T)Name CST# toe-� <br /> CST's ADD SS(Street,City,State,Zi ode) Phone Number: <br /> IX COUNTY/DEPARTMENT USE ONLY <br /> F-1 Disapproved Sanitary Permit Fee Groundwater ate Issuing A ent Signature(No Stamps) <br /> Approved 71 Owner Given Initial Surcharge Fa <br /> Adverse Determ i nation <br /> X. COMMENTS/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copv To.Bureau of Plumbing,Owner,Plumber <br />