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SANITARY PERMIT APPLICATION Cofft <br /> DIL14R In accord with ILHR 83.05,Wis.Adm.Code STATE SANITARY P RMIT# <br /> s 3 131 <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. <br /> –See reverse side for instructions for completing this application. PETITION <br /> I. APPLICANT INFORMATION–PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES ❑ NO <br /> PROPERTY OWNER PROPERTY LOCATION <br /> L 0? {tS .SW % ME- %, S # T N, R $– 8(or)W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME / <br /> 1 rf O Sol .t�/e r e l w•e ' m iA1 6 cJ �pl al <br /> CITyC^ATE r ZIP CODEs3 fI PHONE NUMBER VILLAGE: C a NEAR�T4ROA4,LAK�OR LANDMARK <br /> It. TYPE IOOF BUILDING OR USE SERVED: <br /> OJ ➢/7� <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. 09 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. YConventional 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. See a e Bed b. ❑seepage Trench c. ❑ seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA r;6?7p;,�7eet <br /> M ATION 6. WATER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): fit,C) Private ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in gallons Total #ofPrefab. 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 HoldingTank 7S� I C <br /> Lift Pump 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): Plumber's Signature (No tamps MP/MPRSW No.: Business Phone Number: <br /> Plumber' dd s(Street,City,Slate,Zip Code): Name <br /> 1.1j" w <br /> VIII. SOIL TEST INFORMATION <br /> Cert Soil :ter(�ST) ame CST# <br /> /C <br /> CST's ADDR SS(Street,City,State,zip Cod Phone Number: <br /> W N SYS <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved I Sanitary Permit Fee Groundwater ate Iss n Agent Signature(No Stamps) <br /> Approved ❑ Owner Given Initial (/.y^� �,c�;-)) Sur,har/ge Fee <br /> Adverse Determination 60.C7 �J`� Y �3 <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 />