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ILHR SANITARY PERMIT APPLICATION COE r <br /> In accord With ILHR 83.05,Wis. Adm. Code cyett <br /> STATE SAN IITARY ERM IT# <br /> 4�� b <br /> -Attach complete plans (to the county copy only)for the system,on paper not less than STATE PLAN I.D.NU MBER <br /> 8%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 /> PROPERTY OWNER PROPERTY LOCATION <br /> h _eq A) Yu)% NE1/4, S TgQN, R � � D(or W <br /> PROPER OWNER'S MAILINGADDRESS LOT NUMBER BLOCK NUMBER SUED VISIO NAME <br /> 1 :1 '7 Fc, -a thm, 14V Cl U �qr rcpt! �1 <br /> CITY,S ATE ! ZIP CODE PHONE NUMBER CITY NEAREST RO D,LAKE O LANDMARK <br /> FwMTOWN E-1 VILLAGE : Ig C*4 0 pj �W t <br /> II. FrYPE OF BUIL ING OR USE SERVED: -1 !lIAAA <br /> Number of Bedrooms if 1 or 2 Family o`- OR ❑ Public(Specify): <br /> 111. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4, if applicable) <br /> 1. a. �New b. LI Replacement c. El 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. 11 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. 159 Conventional 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 . 5.SYSTEM ELEVATION 6. WATER SUPPLY: <br /> 3 <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet : <br /> ' G�( �1 0 Ll /S Feet NPrivate El Joint ❑ Public <br /> CAPACIY <br /> VI. TANK Site <br /> in all�nTs Total #of Prefab. Fiber- Expp. <br /> INFORMATION New ng Gallons Tanks Manufacturer's Name Concrete Con- Steel glassPlastic AppTanks s strutted <br /> Septic Tank or Holding Tank 1 7Sm (ZElElLift Pump Tank/Siphon Chamber I Ll ❑ ❑ ❑ <br /> VII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Pluer' Name(Print): Plu <br /> Signature:No Stamps) MP/MPRSW No.: Business Phone Number <br /> �CE[L Hs a a 3� `-Y- 'r - L <br /> Plumber' ddress(Street,City(Stale,Zip Code): Name of r: <br /> W y7;-f ' <br /> VIII. SOIL TEST INFORMATION <br /> Cer ied Soil ester(7 Na CST# <br /> Cl1i X620 <br /> CST's ADDRESS(Str et,City,State,6Code) Phone Number: <br /> 1 COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved I Sany ary Permit Fee Groundwater ate Issuing Agent Signature(No Stamps) <br /> proved ❑ Owner Given Initial <br /> o Surcharge Fee i7, <br /> Adverse Determination (Jl/ C•� Uh`�� <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 />