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DILHR SANITARY PERMIT APPLICATION C TY <br /> In accord with ILHR 83.05,Wis.Adm.Code <br /> STATE SANI ARY PERMIT# <br /> f 3 <br /> —Attach complete plans(to the county copy only)for the system, on paper not less than STATE PLAN I.D.-NUMBER <br /> 8Y x 11 inches in size. <br /> —See reverse side for instructions for completing this application. PE FITION <br /> 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FORVARIANCE ❑YES ❑ NO <br /> PROPERTY OWNER LON ,/^ <br /> S T VO, N, R E (or� <br /> PROPERTY O NER's MAILING ADDRESS LOCK NUMBERL <br /> oNAME.� <br /> CITY, <br /> STATE ✓PP / ZIP CODE PHONE NUMBE CITY [ —/ OADLAKE OR LANDMARK <br /> CYJ�(/ .S�SO•s '7C�1.� .0/O�7U kl 4VC1 <br /> II. TYPE O BUILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family oP 6CC�/"OOrnS 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. 1:1 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. gConventional b. ❑Alternative c. ❑ Experimental <br /> 2. a. ❑System- b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. El 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 5.SYSTEM ELEVATION 6. WA TER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED IS are Feet): P (� <br /> oS e/ /o /y /�• 7 Feet JN�Pi ivate ❑Joint ❑ Public <br /> CAPACITY <br /> VI. TANK Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Ste I glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdin Tank — Q �C ❑ ❑ ❑ ❑ <br /> Lift Pum Tank/Si hon 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): Plumber's Signature:(No tamps) MP/MPRSW No.: Bu iness Phone Number: <br /> 7/S PGG -7aPC, <br /> Plumber's Address(Street,City,State,Zip Code): Name of Designer: <br /> d 1-w1 Ave. s. P,o. ,&X :47s <br /> VIII. SOIL TEST INFORMATION <br /> Cersified Soil Tesler,yyCST)Name CST# <br /> WQC/e 1411,51VIIn 3 P3 <br /> CST's ADDRESS(Street,City,State,Zip Code) Phone Number: <br /> JX4 COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved I Sanitary Permit Fee Groundwater ale Issui g A ent SZOne( mps) <br /> Approved —] Owner Given Initial �) Surcharge Fee 7� <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 I <br />