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SANITARY PERMIT APPLICATION OOUNt <br /> 1:15ILMR In accord with ILHR 83.05,Wis. Adm. Code r <br /> STATE SANITARYPERMIT <br /> Ems LD U'7 <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 �Iddll <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE YES ❑ NO <br /> PROPERTY OWNER_ PROPERTY LOCATION _ <br /> 6idC/' 5E% ���'/a, S T �0, N, R ��O E (or <br /> PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME <br /> ,e 57 <br /> CITY,STATE <br /> ZIP"CODE PHONE NUMBERVILLAGE : NE REST ROAD,LAKE OR LANDMARK <br /> fPi It/Zi3 Ort n i ' Q <br /> 11. TYPE OF BUILDING OR USE SERVE/D:: <br /> Number of Bedrooms it 1 or 2 Family �` , n'i� OR ❑ Public(Specify): <br /> III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) <br /> 1. a. ❑ 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 onnnnee in#1 and only one in#2) <br /> 1. a. ❑Conventional b. I�,.I Alternative c. ❑ Experimental <br /> 2. a. ❑System- b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e.;<Mound f. ❑ IGP <br /> In-Fill Tank <br /> V. ABSORPTION SYSTEM INFORMATION: (Check one) <br /> 1. a. ZSee a e Bed b. ❑See a e Trench c. ❑ seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 15.SYSTEM ELEVATION 6. WATER SUPPLY: <br /> (Minutes er inch): REQUIRED(Square Feet): PROPOSED(Square Feet): /J <br /> -500-5001 00 `70- d r <br /> Feet Private ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in allons Total #of A <br /> Prefab. Fiber- p . <br /> INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App. <br /> strutted <br /> Tanks Tanks <br /> Se tic Tank or Holdin Tank ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber '.� 750 ❑ ❑ ❑ ❑ ❑ <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 Signat e:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> /m 33Lv/ <br /> Plumber's Address(Street,City,State,Zip Code): Name of Designer: <br /> 5- IA/e�tsfCi c/ � .c Q 1-U7qho/ <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name CST <br /> /C1ne eu�h0& <br /> CST's ADDRESS(Street,City,State,Zip Code) Phone Number: <br /> L5 IL <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee Groundwater ate Issuing Agent Signature(No Stamps) <br /> tet, Surcharge Fee <br /> pproved ❑ 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 />