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SANITARY PERMIT APPLICATION 0OU Y <br /> In accord with ILHR 83.05,Wis.Adm. Code r <br /> DILHR <br /> C v STATE ANITARY PE IT# <br /> II G3 <br /> —Attach complete plans(to the county copy only)for the system, on paper not less than STATE PLAN I.D.NU ER <br /> 8'%x 11 inches in size. <br /> —See reverse side for instructions for completing this application. PETITION <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES ❑ NO <br /> PROPERTY OWNER PROPERTY LOCATION ,/,, <br /> ,5 S0 �S (s 0/4 5JE'/4, S T 70, N, R E (or W <br /> PRO TY OWNER'S MAILING ADDRESS O• n )( LOT NUMBER BLIP NUMBER SUBDIVISIONNAMEAin NA AA 17&2A1y)AQA *R(06Z P1 5 <br /> 93 <br /> CITV, TATE ZIP CODE PHONE NUMBER CITY '(DNEEAARREWST'Rryn1OA,D,LAKE OR LANDMARK <br /> ' ((r �p VILLAGE: O LAN aWW <br /> If. TYPE OF UILDING OR USE SERVED: �7 �O <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. n 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. XCOnventional 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.%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): PROPOSED(Square Feet): qII �pl <br /> 2 10 q 3 1 tl I Feet 9.Private ❑Joint ❑ Public <br /> CAPACITY <br /> VI. TANK 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 structed <br /> Septic Tank or HoldingTank k Jr0 L ❑ <br /> Lift Pum 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): Plumber's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> D16FR1c. Acfki/JS � , ' _ C)—10 5 15 &' 157 <br /> Plumber's Address(Street,City,State,Zip Code): Ne of Designer: <br /> 2 w S DEIZI Y— t4DPlc/0S <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name, CST# <br /> oa�WcK, *911 413 <br /> CST's ADDRESS(Street,City,State Zip Code) Q Phone Number: <br /> (..� <br /> I 1 U 3 U6- - <br /> OUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee I Groundwater ate Ise g ant Signature Stamps) <br /> pproved ❑ Owner Given Initial (/Nfj� Surcharge F�eyey� <br /> Adverse Determination 49D. <br /> Llk—/ 52— 50 <br /> X. COMMENTS/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)in,03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber <br />