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—�— SANITARY PERMIT APPLICATION co TY <br /> �, 53ILHR In accord with ILHR 83.05,Wis. Adm. Code u� <br /> �•• --per STATE SANITARY ERMIT# <br /> q/ 04 o_-3D4/ <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 JPROPERTY LOCATION <br /> Orv7� �' 7P N/Af'/4S T (�N, R E (or WPROPERTY OWNER'S MAILING ADDRESS BER BLOCK NUMBER SUBDIVISIO NAME <br /> A14 <br /> CITY,STATE ZIPCODE PH NE NUMBER NEAREST ROAD,LAKEORRLANDMARK <br /> 5StO� / GOF <br /> E <br /> 11. TYPE OF BUILDING OR USE SERVED: <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,it applicable) <br /> 1. a. w b. ❑ Replacement c. ElReplacement of d. LlReconnection 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. 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 /> (Minutes per inch): REQUIRED(Squarree Feet): PROPOSED(Squar /Feet): <br /> Q ( • Feet Private ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in allons Total #of Manufacturer's Name prefab. Con- Steel Fiber- plastic App.INFORMATION New xisting Gallons Tanks Concrete glass App.p. <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank x �1 I rn• ❑ <br /> Lift Pump Tank/Siphon Chamber I ❑ ❑ <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): PI nature:IN to p MP/MPRSW No.: Business Phone Number: <br /> �i'on�7M Ea� um7- �� i% 3m a— 7/1- aW 3S0 <br /> Plumber's Address(Street,City,State,Zip Code), Name of Designer: <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name CST <br /> # <br /> CST's ADDRESS(Street,City,State,Zip Code) Phone Number: <br /> ,e 3 ee -(?0 D9 e fi u>' e 91 2 C/C/ <br /> IX. UNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee Groundwaterate Issuing gent Signature(No Stamps) <br /> Approved ❑ Owner Given Initial h Q S harge Fee - <br /> Adverse Determination <br /> 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 />