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LHR SANITARY PERMIT APPLICATION COSY <br /> In accord with ILHR 83.05,Wis.Adm. Code <br /> S ATESANITARYP RMIT# <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than SAT LAN I.D. MBER <br /> 8'h x 11 inches in size. <br /> —See reverse side for instructions for completing this application. P TITION <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. F R VARIANCE ❑YES ❑ NO <br /> PROPERTY OWNER IRT <br /> TY LOCATION <br /> r S-e rens W y4, S If T OAR R � &(or)W <br /> PROPERTY OWNER'S�MAILING ADDRESS BER BLOCK NUMBER SUBDIVIS O`N NAMEand4ji <br /> CITY,STATE ZIP CODE PHONE NUMBER p k� NEAREST ROAD,LAKE OR LANDMARK <br /> S ro3 OWN OFAGE: $ dtll 1E F <br /> II. TYPE O 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. ® New b. ❑ Replacement c. ❑ Replacement of d. ❑ Reconnection of .❑ Repair of an t <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 Agreem ant 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. ❑X seepage Bed b. ❑seepage Trench c. ❑ seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. V ATER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): <br /> ® q 3 a-- 9Y/ Feet IG ffpp11 <br /> rwate ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in allons Total #of Manufacturer's Name Prefab. Con- St el Fiber- plastic Eger. <br /> INFORMATION New xistin Gallons Tanks Concrete glass App. <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank 7SU T" M L. <br /> Lift Pump Tank/Siphon Chamber 1 ❑ <br /> 11 <br /> VII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plan . <br /> Plumber's Name(Print): Plumber's Signature:(N Stamps) MP/MPRSW No.: siness Phone Number: <br /> a dlt if,cc 1�'ar 0 T 4 - is� <br /> Plumber's Address(Street,City, tate,Zip Code): Name of Designer: <br /> LA..) 14 %7; r Lx-). s S <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soi Tester CST)Nam <br /> l�`E rtC_ kr 1ft2S <br /> CST's ADDR SS(Street,City,State,Zip ode) Phone Nu er: <br /> LN s�tir� w -S - s' YPP 2sa— vee/ -V/S <br /> I*, COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved I S nary Permit Fee Groundwater ate Iss n Agent,ignat r (No Stamps) <br /> Approved ❑ Owner Given Initial �A�.��/ S rchar0V�e-77e�� <br /> Adverse Determination �� ��uV PS K� Zf'L <br /> X. COMMENTS/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Pb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing.Owner,Plumb r <br />