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SANITARY PERMIT APPLICATION CO NTY <br /> L.D1LHR In accord with ILHR 83.05,Wis.Adm. Code N� <br /> ST TE SANITAR PERMIT <br /> ala-7 13 8 <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. <br /> FOR VARIANCE ❑YES ❑ NO <br /> PROPERTYOWNER PrF��OPERTY LCC.*, <br /> OG ION <br /> CiOo dor a, S T , N, R / �(Or W <br /> k%eNp Rn <br /> PROPERTY OWNER'S MAILING ADDRESS LOTNUMBER BLOCKNUMBER SUBDIVISIONNAME <br /> TAR RT. NA A114 NA <br /> CITY,STATE ZIP CODE PHONE NUMBER CIN NE�REST ROAD,LAKE R LANDMARK <br /> Q VILLAGE : lLy <br /> t i / /9 <br /> II. TYPE OF BUILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family J OR ❑ Public(Specify): <br /> III. PURPOSE OFAPPLICATION: (Check only one in#1. Check#2,3 or 4, if applicable) <br /> 1. a. El New b. Le 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 rrOhTF SYSTEM: (Check only one in#1 and only one in#2) <br /> 1. a. [P-I;onventional b. ❑ Alternative C. ❑ Experimental <br /> 2. a. ❑System- b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound I. ❑ IGP <br /> In-Fill Tank <br /> V. ABSORPTION SYSTEM INFORMATION: (Check one) <br /> 1. a. ee a e Bed b. ❑Seepage Trench c. ❑ See a e Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION ZT�ER SUPPLY:(Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): r Feet ivate ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in allons Total of Prefab. Fiber- Expp. <br /> INFORMATION New ExistingGallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> structed <br /> Tanks Tanks ❑ <br /> Septic Tank or Holding Tank /f0170 /OOU / ifC'u. ❑ ❑ <br /> Lift Pum Tank/Sin Chamber O o QO :NAr ❑ <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) MF/MPRSW No.: Business Phone Number. <br /> CE 64 S ' ,` /VeR c �O t S O <br /> Plumber's Address(Street,City,State,Zip Code): Name of Designer: <br /> Qj A -rile (- 44t4- I eECsLI,c 6 <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name CST# <br /> CST's ADDRESS(Street,City,State,Zip Gode) Phone Number: <br /> IX. COUNTYIDEPARTMENT USE ONLY ssuin ent Si natur Wo Stam s <br /> ❑ Disapproved Scann�,itary/Permit Fee Groundwater 5archarge Fee /te / ` 9 g r ( p ) <br /> Approved ❑ Owner Given Initial <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 />