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DILHR SANITARY PERMIT APPLICATION GG TY <br /> In accord with ILHR 83.05,Wis.Adm.Code ST TE SANI ARY ERMIT# <br /> LI <br /> —Attach complete plans(to the county copy only)for the system, on paper not less than STATE PLAN I.D. MBER <br /> 8'h x 11 inches in size. <br /> -See reverse side for instructions for completing this application. PE ITION <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. FO VARIANCE ❑YES ❑ NO <br /> PROPERTY OWNER EPROPERTYION <br /> 4, S T 0, N, R ,B'(cr) W <br /> P OPERTY OWNER'S MAILING ADDRESS BLOCK NUMBER SUBDIVISI N NAME 31y6d 3 8 Al CSM Uot Il ill 3/ — <br /> CITY,STATE IP CODE PHONE NUMBER NEAREST OAD,LAKE OR LANDMARK <br /> ��� <br /> h t <br /> Il. TYPE O BUILDING OR USE SER ED: <br /> Number of Bedrooms if 1 or 2 Family CLOR ❑ Public(Specify): <br /> Ill. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) <br /> 1. a. New b. ❑ Replacement c. L1Replacement 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. K Conventional 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 /> 1Se a e Bed b. ❑Seepage Trench C. ❑ See a e Pit <br /> RLATION RATE 4. ABSORPTION AREA2. P . <br /> 5.SYSTEM ELEVATION 6. WATER SUPPLY: <br /> (Minutes per inch): REOUIRED(Square Feet): PROPOSED(Square Feet): /y <br /> Q 7 Feet UP ivate El joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in allons Total #of 7Conrete <br /> . Fiber- Exper. <br /> INFORMATION New xisting Gallons Tanks Manufacturer's Name Con- Ste I glass Plastic App <br /> Tanks Tanks strutted <br /> Se tic Tank or Holdin Tank 73.0 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): Plu r.s Signature:jNo Stamps) MP/MPRSW No.: Bu iness Phone Number: <br /> pt Jt, k[�r o 0S /_'7 <br /> Plumber's/pddres�s(Street,City,State,Zip Code): Name of Designer: <br /> 5 C`t h L., , <br /> VIII. SOIL TEST INFORMATION <br /> Car"ed So'I Teste`(G$T)Name CST# <br /> R rr C. lip,4,0 <br /> CST's ADDRESS Street,City,State,Zip ode) Phone Numb r: <br /> 7 - <br /> IX. OUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee Groundwater ate Issu' g gent Si nat o Stamps) <br /> ��Approved �' Surcharge Fee 1 <br /> Owner Given Initial r �U <br /> Adverse Determination VIn q007 <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 />