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C3 EH- LHR SANITARY PERMIT APPLICATION D T <br /> In accord with ILHR 83.05,Wis. Adm. Code <br /> mmmmomS ATE SANITARY ERMIT# <br /> q ia7 <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBER <br /> 8%x 11 inches in size. <br /> —See reverse side for instructions for completing this application. PETITION <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. I FOR VARIANCE ❑YES ❑ NO <br /> PROPERTY OWNER IPROPERTY LOCATION <br /> Tr �� LLOTNUMBER <br /> /4 ,LE '/<, S � � 75/O , N, R (� � (or)W <br /> PROPP�E1.RTY OWNER'S MAILIN ADDRESS BLOCK NUMBER SUBDIVISO NAME <br /> CITY, TATE ZIPCODE PHONE NUMBER Y NEAR ROAD�LAKE OR LAN ARK <br /> � LAGE : <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. Lp 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 Agreem ant to County Copy. <br /> IV. TYPE OF SYSTEM: (Check only one in#1 and only one in##2) <br /> 1. a. 1�Conventional b. ❑Alternative c. ❑ Experimental <br /> 2. a. ❑System- b. ❑ Holding C.L1 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. ❑ See a e Trench c. ❑ Seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. W ATER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): Q <br /> `Z l .� 1/ <br /> ( 31 �L_ / Feet PIPrivate rivate ❑Joint ❑ Public <br /> VI. TANK CAPACITYin allons Total #of Prefab. Site Fiber- Exper. <br /> INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steal glass Plastic App <br /> Tanks Tanks structed <br /> Septic Tank or Holding <br /> Tank J'yl :.Sb C ❑ <br /> Lift Pum Tank/Siphon 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): j� PIu is Sig ature:(NoS mps) MP/MPRSW No.: Business Phone Number: <br /> P� Je r-f, lTc /flhf 6 � 6' T- !S ¢6"�� r7 <br /> Plumber's Address(Street,City,State,Zip Code): Name of De igner: <br /> VIII. SOIL TEST INFORMATION <br /> Certi d_S/q�I Testes(CST) / CST Na# <br /> it �1 �C' <br /> CST's ADDRIStreet_Gily,State,Zip ode) rer, <br /> -f, s- -er W ' _7 �P, C66- 4YI 7 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved I Sanitary Permit Fee Groundwater ate Issu g Agent S at re(No Stamps) <br /> &proved ❑ Owner Given Initial S charge Fee <br /> Adverse Determination a� G� <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,Plumbe <br />