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Q �I�HR SANITARY PERMIT APPLICATION cLIY(Gle 1 <br /> In accord with ILHR 83.05,Wis.Adm. Code <br /> STATE SANITARY P RMIT# <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 /> 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES ❑ NO <br /> P-�RROPERTY OWNER / PROPERTY LOCATION / <br /> 1 ti n e a'f d � � ►4 + �I rev i k"/< /lJE'/e, S T (� N, R E (or) W <br /> PROPERTY OWNER'S MAILING ADDRRESS LO; UMBER BLOC;NUMBER SUBDI�ION NAME <br /> CITE FF'' r•• ZIP CODE PHONE NUMBER ,CVITY /" riF NEARESTAOAD,LAKE OR LANDMARK <br /> _te <br /> O VILLAGE : 3 6Vl rs, 1 , e),& („ �/V <br /> rIc ceTr Wi, <br /> 11. TYPE OF BUILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family OR ❑ Public (Specify): <br /> Ill. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4, if applicable) <br /> 1. a. N 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. 5dconventionai 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 /> c <br /> 1. a. [�Seepage Bed b. ❑ Seepage Trench C. ❑ See a e Pit <br /> 2. PERCOLATION RATE 3, ABSORPTION AREA 14. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: <br /> (lutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): <br /> 3 y/0 q � � C/g, <br /> Feet Private ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in allona Total #of Prefab. Fiber- Expp. <br /> INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks structed <br /> Septic Tank or Holding Tank 7s` SU ( Af C_ 0 El ❑ ❑ <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:( o Stamps) MP/MPRSW No.: Business Phone Number: <br /> a r v-r C) e n s 03 d S 7 7/ f6 4­Y1T <br /> Plumber'sAddress(Street,City,State,Zip Code): Name of Designer: <br /> Y <br /> VIII. SOIL TEST INFORMATION <br /> Certif d Soi Tester(CST)Name CST# �! <br /> 17 <br /> C DD SS(Street, it t te,Zip ode) Phone Number: <br /> s A /r7 <br /> IX. COUNTY/DEPARTMEN U ONLY <br /> ❑ Disapproved Sanitary Permit Fee Groundwater ate ipq IssuAgent Signature No Stamps) <br /> pproved ❑ Owner Given Initial S rcharge Fee <br /> Adverse Determination <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 />