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SANITARY PERMIT APPLICATION COUNTY .e�— <br /> 7 0ILHR In accord with ILHR 83.05,Wis.Adm.Code <br /> s STATE SANITARY PERMIT <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 /> 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. I FOR VARIANCE ❑YES ❑ NO <br /> PROPERTY OWNER ,C� PROPERTY LOCATION <br /> IV0��( GoLe,L /�2Q�/ -ru1/4 SE '/aS T0, N, R /0 &(or)W <br /> PROPERTY OWNER'S MAILIN DDRESS LOT NUMBER BLOCK NUMBER S/U�BDIVI ION NAM r <br /> Ci 1'-3 s- v(!rT �Qi- tatS Cvv!' /•V`ef <br /> CLITY'STATE, ZIP CODE PHONE NUMBER CITY NEAREST ROAD,LAKE OR LANDMARK <br /> / f AC A�It `�U� ❑ VILLAGE <br /> If. TYPE OF`13UILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family 2 OR ❑ Public(Specify): <br /> III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4, if applicable) <br /> ISI <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. CYFconventionai 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. M See a e Bed b. ❑ See a e 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): Q <br /> "��� 7 � � l `�'� Feet Private ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in allonS Total #ofPrefab. Fiber- Exper. <br /> INFORMATION New xisting Gallons TanksLManufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or HoldingTank J�o M C_ 1 <br /> ❑❑ El ❑ ❑ <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): Plu per's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> kt 4-t r-;c, n �140� Q 0 S' /, W-W-f- <br /> Plumber's Address(Street,Of .Slate,Zip Code): Name of Qesi ner: <br /> "/L�/ <br /> Vlll. SOIL TEST INFORMATION <br /> Certified So/)I Tester(CST)Name CST# <br /> 0 c( hLGOlej;2 <br /> CST's ADDRES (Stre City,State,Zip Co e) Phone Number: <br /> �a\,O— is r U_.� s V - <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee Groundwater ate Issui gent Sign t e(No Stamps) <br /> Approved ❑ Owner Given Initial �j {/rnc-r� Su charge Fee <br /> PP Adverse Determination or wL 4�6, ` � <br /> X. COMMENTS/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)R.03/86) DISTRIBUTIONOriginal to County,One Copy To:Bureau of Plumbing,Owner,Plumber <br />