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SANITARY PERMIT APPLICATION CC UNITY <br /> . DILH R In accord with ILHR 83.05,Wis. Adm. Code <br /> ST ATE SANITARYPE MIT# <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than ST TE PLAN I.D.N BER <br /> 8'h x 11 inches in size. <br /> —See reverse side for instructions for completing this application. <br /> PETITION <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FC R VARIANCE ❑YES ❑ NO <br /> PROPERTY OWNER TION <br /> S'P re S C n) s , S T q0 N, R re(orPROPERTY OWNER'S MAILING ADDRESS BLOCK NUMBER SUBDIVISI N NAME <br /> e k C S ec l <br /> CIT STAT / ZIP CODE PHONENUMBERIE <br /> NEAREST OAD,LAKEORLA DMARK <br /> f " it c lQ/r� � Ua_ �'+y r <br /> II. TYPE OF B LDING 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. 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 AgreemE nt to County Copy. <br /> IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2) <br /> 1. a. IN Conventional b. ❑Alternative C. ❑ Experimental <br /> 2. a. ❑System- b. ❑ Holding C.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. El IGP <br /> In-Fill Tank <br /> V. ABSORPTION SYSTEM INFORMATION: (Check one) <br /> 1. a. 19See a e 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(Square Feet): r'' <br /> oma- 0 7 l�( Feet y�P ivate ❑Joint ❑ Public <br /> VI. TANK CAPACITY <br /> in gallons Total #of Prefab. Site Fiber- ft <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Ste I glass Pl <br /> Tanks Tanks structed <br /> Septic Tank or Holding <br /> Tank 1 C. <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 _r's Signature (No Stamps) MP/MPRSW NNoo,: Bu iness Phon(e''Number: <br /> c C Q'. V`R'���l l<A'l f © 1 .1 r d <br /> Plumbers Address(Street,City,Stale,Zip Code): Name of Designer: <br /> W 7- r— _s <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name CST# <br /> QrC�7 S �() <br /> CST s D DRE Street,City,State,Zi Code) Phone Number: <br /> LV (e �� l S E ( � <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee Groundwater ate Is su' ent Si nature o Stamps) <br /> Approved ❑ Owner Given Initial �q�.�r,7 rcharge/Fgeee <br /> Adverse Determination &�" "' as'v�,l ✓ /J U" <br /> X. COMMENTS/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.03/86) DiS'TRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber <br />