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SANITARY PERMIT APPLICATIONco NTY <br /> LDILHR In accord with ILHR 83.05,Wis.Adm. Code <br /> STATE SANITARY ERMII# <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. FOR VARIANCE ❑YES ❑ NO <br /> PROPERTY OWNEfl PROPERTY LOCATION <br /> Grgr IIJ-PLSenr PE % fEix , s a? T3�, N, R /7 ID(or) W <br /> PROPERTY OWNER'S MAILING ADDRESS LOTNUM ER BLOCCe UMBER SUBDIV SION NAME <br /> R fi L ,e n V;0�Ir / yLIL )/t N <br /> CITY,STATE ZIP CODE PHONE NUMBER CITY / BW <br /> R AD,LAKE ORLANDMARK <br /> ,S ( PCIJ Wj, S` 0 �. VILLAGE ; DQ410 C1' )[ CL <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 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.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound I. ❑ IGP <br /> In-Fill Tank <br /> V. ABSORPTION SYSTEM INFORMATION: (Check one) <br /> 1. a. [9 Seepage Bed b. ❑ Seepage Trench c. ❑ Seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet). G <br /> iY / S 6 ZIP / 0' Feet M Private ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in all ns Total #of Prefab. 1LJ <br /> Exper. <br /> INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- SteePlastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdin Tank S 7s I /^-r�' ❑ <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): Plu tier's Signature: o Stamps) MP/MPRSW No.: Business Phone Number: <br /> s 7IS- fU% f lT7 <br /> Plumber's.A�dd��r.ggsss�s(Street,City,State,Zip Code): N of signer: <br /> Wt. I_A�- F <br /> VIII. SOIL TEST INFORMATION <br /> Cer"tied S it Tester(CST)Name CST# <br /> fY e.r`r G^ )L f-VL r <br /> C ADDR SS( trees,City,StatZ ode) �� Phon/,urmbe <br /> s �y y/C- 7 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved S nitary Permit Fee Groundwater ate Issui Agent Si tune(No Stamps) <br /> pproved ❑ Owner Given Initial S rcharge�Fee <br /> Adverse Determination <br /> X. COMMENTS/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)F.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber <br />