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SANITARY PERMIT APPLICATION COUNTY <br /> (�I DILHR In accord with ILHR 83.05,Wis.Adm.Code tune* <br /> STATE SANITARY PERMIT <br /> aI jo C I3 <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.M.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. FOR VARIANCE ❑YES ❑ NO <br /> PROPER eT <br /> OjNy,ER OS 1e Ya <br /> PROPERTY LOCATION <br /> JJ\\ Y/1 T!) ' S6 , S 2_�v T'/O , N, R 111 E{or W <br /> PROPERTY OWNER'S MAILING ADDRESS rLOTNUMBER BLOCK NUMBER SUBDIVISION NAME <br /> LAA ceaa:�jj <br /> CITY,STAT ZIP``LCLODE PHONE NUMMB�EIR CITY NEARES OA LAKE OR`ANDMARK <br /> 02111 Z 7L Orb—d 0 VILLAGE: <br /> TOWN OF' M ID h 4fW-&j;A PA41 <br /> 11. TYPE OF 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. 19 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 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.11 Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP <br /> In-Fill Tank <br /> V. ABSORPTION SYSTEM INFORMATION: (Check one) <br /> 1. a. Seepage Bed b. ❑Seepage Trench c. ❑ Seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 15.SYSTEM ELEVATION 6. WATER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): q'1 ?? lq1 <br /> 3 -3 - 3 6/,y 6 /.),,33 Feet Fv Private El joint EJ Public <br /> VI. TANK CAPACITY Site <br /> in allons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- plastic Exper. <br /> INFORMATION New xisting Gallons Tanks Concrete strutted glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank __X7 loco ! I Ulieser4c ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ 1 ❑ ❑ ❑ ❑ <br /> VII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility fo installation of the private sewage system shown on the attached plans. <br /> Plumber's Name(Print): PI er's nature ( tamps) MP/MPRSW No.: Business Phone Number: <br /> uil o>°r r MPT"78 /,S- ?,--,%0e <br /> PI bar's Address(Street,City State,Zip Code): Name of Design�� <br /> L �$� l.S /Coe <br /> VIII. SOIL TEST INFORMATION <br /> CE=Tester(CST)Name? / CST# 1 <br /> CST's ADDRESS(Street,City,Sta ,Zip Code) Phone Number: <br /> /S S ?i3 --;t-mg <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee Groundwater ate Issuing ent Signature(No Stamps) <br /> S rcharge Fee - <br /> Approved ❑ Owner eDetermin /_� qn ;6, <br /> n J G <br /> Adverse Determination �f Vv /D O �Z IwIAV <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 />