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SANITARY PERMIT APPLICATION CC ATY <br /> �ILHR In accord with ILHR 83.05,Wis. Adm.Code t5i r <br /> ST ITI SAN ITAR PERMIT# <br /> 3 <br /> —Attach complete plans (to the county copy only)for the system,on paper not less than STATE PLAN I.D. UMBER <br /> 8'%x 11 inches in size. <br /> —See reverse side for instructions for completing this application. PE TITION <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FC R VARIANCE ❑YES ❑ NO <br /> PROPERTY OWNER PROPERTY LOCATION <br /> !�7c yr Sr-gs � nr Sw '%s sfiz. ''/a, S 7 TN, R k Q (or) W n <br /> PROPERTY/�NEfrR^'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUUBDIYISI N NAME_f <br /> CITY,STATE ZIP CODE PHONE NUMBER CITY %�!/T1 NEAREEEST d0/AdD/,LAKE ORLANDMARK <br /> fil h[ T SS03 VILLAGE : U F A— 44*1 <br /> TOWN OF RGV� H <br /> II. TYPE 4 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. 0 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 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. ® Seepage Bed b. ❑Seepage Trench c. ❑ Seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA5.SYSTEM ELEVATION 6. Wo TER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): C� ISI <br /> d. 7/ Q 3 Z)— ( �� Feet lGPrivate ❑Joint ❑ Public <br /> CAPACITY 1 Site <br /> VI. TANK in allons Total #of Manufacturer's Name Prefab. Con- Ste I Fiber- plastic Exper. <br /> INFORMATION New xis <br /> tin Gallons Tanks Concrete glass App. <br /> Tanks Tanks at <br /> Septic Tank or HoldingTank X <$`O T ❑ <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): Plu er's Signalu e:(No Stamp MP/MPRSW No.: Business Phone Number: <br /> il�6 4 phi( k O inS I tq.b/ d30-�) e fl6 lJ <br /> Plumber's Address(Street,City,State,Zip Code): Name of Designer: <br /> VIII. SOIL TEST INFORMATION <br /> Cellified S iiI`es l r(CST)Name h CST# <br /> VCSTT's ADDRE S(Sttrrl-eeeet,'City,`State,Zip Code) Phone Number: <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Ej <br /> Disapproved S nitary Permit Fee Groundwater ate I ui Agent Si t e(No Stamps) <br /> Approved ❑ Owner Given Initial ,/p�I�� rcha{rg/e Flee <br /> Adverse Determination <br /> X. COMMENTS/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)In 03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber <br />