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O 6ILHR 'SANITARY PERMIT APPLICATION col <br /> 7. s H In accord with ILHR 83.05,Wis. Adm. Code In rnzbt-- <br /> STATE SANITARY P MIT# <br /> a01 [L7 <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBER <br /> 8'h 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 /> PROPER Y OWNER PROPERTY LOCATION <br /> MC- t s '/4 .SF Y4, $ 31 T 0, N, RB (O W <br /> PROPERTY OWNER'S MAILING ADDRESS LOTNUMBER BLOCK NUMBER SUBDIVISION NAME <br /> 3 460 )( 3 N A- A/ A-- b #. it 4-r r C/ <br /> CITY,STATE ZIP CODE PHONE NUMBER CITY NEAREST ROAD,LAKE OR LANDMARK <br /> VILLAGE : —4 <br /> te <br /> II. TYPE OF BUILDING OR USE SERVED: ` D <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.XAlternative c. ❑ Experimental <br /> 2. a. ❑System- b,XHolding c.11 Pit Privy d. ❑ Vault Privy e. ❑ Mound I. ❑ 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 14. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): <br /> Feet ❑Private [I joint 1:1 Public <br /> VI. TANK CAPACITYin allons Total #of Prefab. Site Fiber- Exper. <br /> INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdin Tank .1000 ( * /t'L G.. ❑ ❑ <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): Puy/l� r's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> /l 0 L✓e c VI 0 a <br /> Plumber's Address(Street,City,State,Zip Code): Name of Designer: <br /> Tr S- <br /> Vlll. SOIL TEST INFORMATION <br /> Certified SoilTester( ST)Name�� // CST# <br /> G-4ar ;-Wi l-d�> 6 C� <br /> CST's ADDRESS(Street,City,State,Zip Code) Phone Number: <br /> r— P /s X66- Yrs7 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved nitary Permit Fee Groundwater ate Issuin gent Signature(No Stamps) <br /> /y�� � <br /> Approved El Owner Given Initial $charge Fee uLl' 25 6- <br /> , b L—f: � <br /> Adverse Determination U / OU <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 />