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�ILHR SANITARY PERMIT APPLICATION co NTY <br /> In accord with ILHR 83.05,Wis. Adm. Code <br /> ST TESANITARY ERMIT# <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. 5 89- a <br /> -See reverse side for instructions for completing this application. PE ITION <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. FO I VARIANCE ❑YES ❑ NO <br /> PROPERTYOWNER p PROPERTY LOCATION <br /> C .1prale t-74 s UASE%, S S T 3QN, R (z 1 (or) W <br /> PROPERTY OWNER'S MAILING A DRESS LOT NUMBER BLOCK NUMBER SUBDIVISIC N NAME <br /> N A A� N <br /> CITY,STATE ZIP CODE PHONE NUMBER 0 CITY NEARES OLD, AKE OR LANDMARK <br /> SI OF <br /> �N lam/ s �d [A TOW❑ VILLAGE S rC W S� <br /> 11. TYPE OF BUILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family OR ® Public(Specify): /S r ! 9i &L o <br /> III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) <br /> 1. a. �q New b. ❑ Replacement G. ❑ 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 Agreementto County Copy. <br /> IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2) <br /> 1. a. ❑Conventional b. X 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 AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): p oI <br /> 0 '] a 0 / Q r Feet Y&Pi ivate ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in allons Total #of Manutacturer'sName Prefab. Con- Ste Fiber- Plastic Exper. <br /> INFORMATION New xisting Gallons Tanks Concrete glass App. <br /> Tanks Tanks structed <br /> Septic Tank or Holding Tankd.otl0 ( L•J G <br /> Lift Pump Tank/Siphon Chamber �S`0 Lr-t—IIIElEl <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): Plumber's Signature(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> ID I er,I a 3 tr a s- P66� �d 7 <br /> Plumber's Address(Street,City, tate,Zip Code): Name of Designer: <br /> W WiO 's, Et <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name CST# <br /> QdtiN'LG �- <br /> CST's ADD SS�Street,City,State,Zip ode Phone Numb r: <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved I Sanitary Permit Fee TGroundwater at Iss y Agent Si ture(No Stamps) <br /> Approved ❑ Owner Given Initial r� Surcharge Fee <br /> � <br /> Adverse Determination � W <br /> X. COMMENTS/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Ccpy To:Bureau of Plumbing,Owner,Plumber <br />