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DISANITARY PERMIT APPLICATION CO TY <br /> LHR <br /> =� s H In accord with ILHR 83.05,Wis. Adm. Code STATE SA ITARY ERMIT# <br /> aia4+ �3 ► <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBER <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 /> PROP RTYf9 WNER PROPERTY LOCATION <br /> 4COe Q �t`f E1/4.W '/4, S � fTVIN, R �� E (or) W <br /> PR P RTY OWNEe S M41LINGOADMES P LOT NUMBER BLOCI$IJUMBER SUB))ISk1N NAME <br /> sm <br /> Pvt <br /> CIT ,S6TAT� O1P f4 ZIP CODED PHONE NUMBER CITY NEAREST ROAD.LAKE OR LANDMARK <br /> r.J VJ-/� O VILLAGE : <br /> 11. TYPE OF BUILDING OR USE SERVED: \1 <br /> Number of Bedrooms if 1 or 2 Family OR ❑ Public(Specify): <br /> Ill. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) <br /> 1. a. D9 New b. ❑ Replacement c. ❑ Replacement of d. ❑ Reconnection of e.❑ Repair of an <br /> System System Septic Tan Only an Existing System Existing System <br /> 2. A Sanitary Permit was previously issued. Permit# ()-1:�q -r7 Date Issued h—M- <br /> 3. LI 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. 2poeepage 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): Of/ DI <br /> Private Z f J Feet ILPrivate ❑Joint ❑ Public <br /> VI. TANK CAPA TY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xisling Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> I El <br /> Se tic Tank or Holding Tank72'v ❑ ElLift 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): PI 's Signature: o Stamps) MP/MPRSW No.: Business Phone Number: <br /> n <br /> 02 a a 9 <br /> Plumber' Addres (Street, ity,State,Zip Code): N e o signer: <br /> VIII. SOIL TEST INFORMATION <br /> Car d S 'I Testet(CST)Name <br /> CST#ry <br /> 6 `cr c k l2S / <br /> CST's ADq/iES.. (StreeCity,State,Zip Code) Phone Number: <br /> X. OUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved I Sanitary Permit Fee Groundwater ate Issuing gent Signature(No Stamps) <br /> A roved 6o e� r�c am _.�n �✓J <br /> pp ❑ Owner Given Initial _J• <br /> Adverse Determination <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 />