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SANITARY PERMIT APPLICATIONNTY <br /> O' DILHR In accord with ILHR 83.05,Wis.Adm. Code U P ,e '}/+ <br /> TESP�(JIT RYP RMIT# <br /> (Jf S <br /> —Attach complete plans(to the county copy only)for the system,On paper not less than STATE PLAN I.D.NUMB ER <br /> 8'h x 11 inches in size. <br /> —See reverse Side for Instructions for completing this application. PE rITION <br /> 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. F VARIANCE ❑YES ❑ NO <br /> PROPERTY OWrER EPROPERTYIONCLOv�GiQ GOUVI,V\ , S j � T qN, R 6 -etoPR ERTY OWNER'S MAILINGADDRESS BLOCK NUMBER SUBDIVISI N NAMIr <br /> VV,Cto `i V f �ITY, T TE Z�IPP C//OpDDE PHONE NUMBER NEAnR�EtST CAD KE R LAND/MMAARK <br /> t \ �t J 't f7�� 'r Q K'O"t { vtl yt0 (Al �/LQ <br /> II. TYPE O 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,if applicable) <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. XConventional b. ❑ Alternative C. ❑ Experimental <br /> 2. a. ❑System- b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound I. IGP <br /> In-Fill Tank <br /> V. ABSORPTION SYSTEM INFORMATION: (Check one) <br /> 1. a. X Seepage Bed b. ❑Seepage Trench c. ❑ Seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. W) TER SUPPLY: <br /> J (Mi fes per inch): REQUIRED(Square Feet): PROPO ED^(Square Feet): / <br /> f — 4 l p 1; V 7 ' Fee ix P ivate ❑Joint ❑ Public <br /> CAPACITY <br /> VI. TANK Site <br /> I allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Ste I glass Plastic App <br /> Tanks Tanks 1' 1 strutted <br /> Septic Tank or Holding Tank �tJlt'St/- Cpc <br /> Lift Pump Tank/Siphon Chamber F-H ❑ ❑ <br /> VII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility fir installation of the private sewage system shown on the attached plans. <br /> Plumber's Naa(Print): PI tuber' ignalu Stamps) MP/MPRSW No.: Bu iness Phone Number: <br /> 42 <br /> P be,'sss(Str t,City, tatoi�e ICOd t Name ot�esipner:J )k p r <br /> III. SOIL TEST INFORMATION <br /> r /fv/ �S <br /> Certified Soil Tester(CST)Name � L CST# ' <br /> WW /AVAIJ 1 <br /> CST's 41 D SS(Street,City,State, Cod ) , Phone Number <br /> r <br /> II �oJU (/ � ;)V— 736(e,;, <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved I Sanitary Permit Fee I Groundwater ate Issuing Agent Si nature(No Stamps) <br /> Q Su c^harge qFe�e <br /> Approved ❑ Owner eDetermi al D(r',� <br /> Adverse Determination <br /> X. COMMENTS/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)in,03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber <br />