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SANITARY PERMIT APPLICATION I Co I NTY // <br /> In accord with ILHR 83.05,Wis. Adm. Code UrrteT� <br /> O DILHR <br /> ST TE SANITARY ERMIT# <br /> q7 a� a <br /> —Attach complete plans(to the county copy only)for the system, on paper not less than ST TE PLAN I.D.NUMBER <br /> 8'F: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. FOR VARIANCE ❑YES ❑ NO <br /> PPERTYOWNER PROPERTY LOCATION <br /> l / <br /> vh C— <br /> BO �F NE %5 %, S /1P Tyl , N, R IqE-*, W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER I SUBDIVISION NAME <br /> S f i 'B o X S37 <br /> CITY,STATE ZIP CODE PHONE NUMBER CITY NEAREST LAKE OR LANDMARK <br /> bb L K. <br /> W t S qt 3a (S aV - TOWN OFVILLAGE l ,1e6b 4k-e-1 <br /> 4 OYI 4 <br /> II. TYPE OF BUILDING OR USE SERVED: W <br /> Number of Bedrooms if 1 or 2 Family oZ 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. R 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. XSeepage Bed b. ❑Seepage Trench c. ❑Seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 15.SYSTEM ELEVATION 6. WATER SUPPLY: <br /> (Minutes per inch): REO�U/`R/ED(Square Feet): PROPOSED(Square Feet): q �� <br /> Feet TgP ivate ❑Joint ❑ Public <br /> CAPACITY <br /> VI. TANK in allons Total Site <br /> INFORMATION #ot Manufacturer's Name prefab. Con- Ste I Fiber- plastic Exper. <br /> New xisting Gallons Tanks Concrete strutted glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank ('PSP/^ 00409%E KI <br /> Lift Pum Tank/Siphon Chamber ❑ ❑ ❑ <br /> VII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility f4 installation of the private sewage system shown on the attached plans <br /> Plumber's Name(Pr nt): mbar' Signet re o Stamps) MP/MPRSW No.: Business Phone NumberlVe : <br /> IS <br /> O-er r PI RP S7FV /S 6 <br /> PI u bar's Address(Street City State,Zip Code): Name of esigner: <br /> 2— W �ej- Wits 5"(213 Iva S rote Yr <br /> VIII. SOIL TEST INFORMATION <br /> Certif d Soil Tester(CST)Na a CST <br /> # <br /> 0a jre e/4 3s 7 / <br /> CST's ADDRESS(Street,City,State,Zip de) Phone Numb r: <br /> sib P is ��b �/r <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee Groundwater ate Iss Agan[Si lure No Stamps) <br /> Approved ❑ Owner Given Initial (Ll/ry,�) _chaCCrgeryFFe�e <br /> Adverse Determination "" "� , JA VV q L!�5� <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 />