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fl D1tHR SANITARY PERMIT APPLICATION C NTY <br /> s � In accord with ILHR 83.05,WIS.Adm.Code ST TESAN ITARYPER MIT# <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN Vn.NUMBER <br /> 8'h x 11 inches in size. <br /> —See reverse side for instructions for completing this application. PE TITION <br /> 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES ❑ NO <br /> PROPERTY OWNER PROPERTY LOCATION <br /> Orr CF/-Sen? ITt-i . S['/., S /_3 T N, R 5^@(or)W <br /> PROPERTY It�R'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME <br /> Ea .--r—vv 6�rC4 ?Gr <br /> CITY, ATE�_/ nn..,,�� � IDN ZIP CODE PHONENUMBER CITY NEARES' O D,LAKEORLA DMARK <br /> `�• Nv`-'J S51 ❑ VILLAGE : T <br /> JYC � lrx � "S�vK L Fie <br /> 11.iTYPE BUILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family OR ❑ Public(Specify): <br /> 111. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) <br /> 1. a. ❑ New b. N 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 Agreenrl nt to County Copy. <br /> IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2) <br /> 1. a. M Conventional 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. N Seepage Bed b. ❑Seepage Trench C. ❑ See a e Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 15.SYSTEM ELEVATION 6. WATER SUPPLY: <br /> ( nutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): <br /> q Q ("yam <br /> `S (C / ��1 Feet 91 ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in gallons Total #ofPrefab. Fiber- Exper. <br /> INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Ste glass Plastic App <br /> Tanks Tanks strutted <br /> Se tic Tank or Hold in Tank CC V,1' 'L ❑ ❑ I ❑ <br /> Lift Pum Tank/Siphon Chamber ❑ L-1 ❑ 1:1 <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 /> P u tier's Address(Street,City,State,Zip Code): Nam f Designer: ` <br /> VIII. SOIL TEST INFORMATION <br /> Certified oil Tester(CST)Name CST# <br /> e+ tt S <br /> CST's ADD SS(Street,City,staid,Zip Code) Phone Numb r: ' <br /> 'e f t3j S J6 /J <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> E] Disapproved Sanitary Permit Fee Groundwater ate Issui Ag nt Si nature tamps) <br /> Approved ❑ Owner Given Initial --fw-m Surcharge Fee.0p `7-8� <br /> Adverse Determination <br /> a5 �� <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 />