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O OILHR SANITARY PERMIT APPLICATION COUNTY <br /> In accord with ILHR 83.05,Wis.Adm. Code STATE SANITARY PERMIT# <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than ST TE PLAN I.D. UMBER <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. FOR VARIANCE ❑YES ❑ NO <br /> PROPERTY OWNER PROPERTY LOCATION <br /> iv+.. o NE '/•sem '/., S l TyQN, R S� (or) w <br /> PR PERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVIS ON NAME <br /> r(li. SAY! <br /> CITY,S T ZIP CODE` PHONE NUMBER VILLAGE: �c-Tio -1 NEAT o ROAD,LAKE_O�ANDMARK <br /> tt c�"� 3" 8g 3 SSSJJJ N /!�J <br /> II. TYPE OF BUILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family 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 AgreemE nt 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.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. IGP <br /> In-Fill Tank <br /> V. ABSORPTION SYSTEM INFORMATION: (Check one) <br /> 1. a. 25 Seepage Bed b. ❑ Seepage Trench C. ❑ See a e Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA5.SYSTEM ELEVATION 6. W TER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): [� <br /> /() ;L__ 1 Feet MPivate ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in gallons Total #of Manufacturer's Name Prefab. Con- Ste I Fiber- plastic Exper. <br /> INFORMATION New xisting Gallons Tanks Concrete glass App. <br /> Tanks Tanks strutted <br /> Septic Tank or Holdin Tank Co Cto 1 U I ❑ Ej <br /> ❑ <br /> Lift Pump 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 ame(Print): Plu ign lure:(No Sl ps) MP/MPRSW No.: Business Phone Number: <br /> cl vrtc — a �in b ; 0 *S- 7,T) X66` /f7 <br /> Plumber's kddress(Street,City,State,Zip Code): Nam Designer: <br /> VIII. SOIL TEST INFORMATION <br /> Ce tl S;ester(CST)Name CST# 7 <br /> Q frac I\ d 7�1Q2 f i / <br /> CST's ADDR S(Str et,City,State,Zip C de) Phone Number: <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee Groundwater ate ssui A ent Si nal a No Stamps) <br /> Approved F-1OwnerGiven Initial % cc Surcharge/Femme <br /> Adverse Determination OOVV _)35' <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 />