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(—�� SANITARY PERMIT APPLICATION COUNTY <br /> ( 31LHR In accord with ILHR 83.05,Wis. Adm. Code <br /> S ATE SANITARY P RM IT# <br /> –Attach complete plans(to the county copy only)for the system,on paper not less than SATE PLAN I.D.NOME <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 /> P894RTY OWNER PROPERTY LOCATION <br /> n- 05tr V C A)U)11aSUY4, S3$' T QN, R S— S (or)W <br /> PROPERYY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISI N NAME <br /> x 888 N-eC< nc. F4v. /v R ill <br /> CITY,STATE ZIP CODE PHONE NUMBER CITY 1.. NEAREST OAD,LAKE OR LANDMARK <br /> St Por /y �S I I bia _37 1M TOWN OF:3 VILLAGE: qC /1 S C N� G/ -em 4E If <br /> It. TYPE OF BUILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family C;L OR ❑ Public(Specify): <br /> III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) <br /> 1. a. M 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 Agreem nt to County Copy. <br /> IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2) <br /> 1. a. r6Conventional 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 15.SYSTEM ELEVATION 6. W kTER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): j <br /> � <br /> 0 Y" ! / b Feet y�F rivate El Joint ❑ Public <br /> VI. TANK CAPACITY <br /> in allons Total #of Prefab. Site Fiber- Exper. <br /> INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Ste glass Plastic App <br /> Tanks Tanks structed <br /> Septic Tank or Holding Tank 7.S' ( L1ElLift Pum Tank/Si hon Chamber IE ❑ ❑ ❑ <br /> VII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plan <br /> Plumber's Name(Print): I Plu s Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> 5 roc 'n 0305' /J 17 <br /> Plumber's(Address(Street,Citj,State,Zip Code): Name of Designer: <br /> 6 W Y 0 <br /> VIII. SOIL TEST INFORMATION <br /> Cert 'ed tl S it Tester(CST)Name CST# <br /> 1It - <br /> Z AS <br /> CST's ADD ESS(Street,City,State, p Code) Phone Num er: <br /> W,* S�r �v Q3 - sfl <br /> IX COUNTY/DEPARTMENT USE ONLY <br /> Disapproved S itary Permit Fee Groundwater ale Iss gent Sin r (No Stamps) <br /> pproved ❑ Owner Given Initial /�{� SQyr�rc arge FNee Iq `��'^!-7(��'-/J <br /> Adverse Determination )U ,, �J't�� —" — r <br /> X. COMMENTS/REASONS FOR DISAPPROVAL: <br /> SBO-6398(formerly Plb-67)in,03/86) C 37RIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber <br />