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fl C3iLHR SANITARY PERMIT APPLICATION COUNTY <br /> In accord with ILHR 83.05,Wis. Adm. Code urnett <br /> �•�"�^�•-^---�- <br /> STATE SANITARY ERMIT# <br /> ISI 7 <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.—NUMB... <br /> 81/2 x 11 inches in size. <br /> —See reverse side for instructions for completing this application. PETITION <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. F R VARIANCE ❑YES © NO <br /> PROPERTY OWNER JPROPERTY LOCATION <br /> Maxine Mashek +/4 SE +/4, S 21 T38 , N, R1 fxO*W <br /> PROPERTY OWNER'S MAILING ADDRESS UMBER BLOCK NUMBER SUBDIVISI N NAME <br /> Rt. 1 na na <br /> CITY,STATE ZIPCODE PHONE NUMBERTY NEAREST OAD,LAKE OR LANDMARK <br /> Siren, WI 54872 __ LLAGE: Daniels TOWN OF Dunham Lake Rd. <br /> It. TYPE OF BUILDING 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 /> 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 Agreem nt 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. 12 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 /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): <br /> 3 410 420 94.40 <br /> Feet ©P wate ❑Joint El Public <br /> VI. TANK CAPACITY Site <br /> in allons Total #of Manufacturer's Name Prefab. Con- Ste Fiber- plastic Exper. <br /> INFORMATION New xistin Gallons Tanks Concrete glass App. <br /> Tanks Tanks �— strutted <br /> Septic Tank or Hold in Tank 0 0 0 1 TMC Inc. EJ I <br /> Lift Pum Tank/Si hon 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): Plu bar's Signature:tNo Stamps) MP/MPRSW No. I Bu oness Phone Number: <br /> Donald Daniels MP 330 715 349-5533 <br /> Plumber's Address(Street,City,State,Zip Code): Name of Designer: <br /> Box W Siren, WI 54872 same <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name CST# <br /> Joan E_ Daniels !349-5533 <br /> 1 <br /> CST's ADDRESS(Street,City,State,Zip Code) Phone Nur: <br /> Fox W Siren. WI 4872 15 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee Groundwater ate Issuing Agent Si nature(No Stamps) <br /> Approved ❑ Owner Given Initial S charge Fee <br /> 8a•�0a5.oc� /b-as-�sJ `mom <br /> Adverse Determination <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 />