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LHR SANITARY PERMIT APPLICATION C)UNITY <br /> LLPIIn accord with ILHR 83.05,Wis.Adm. Code <br /> S ATE SANITARY PERMIT <br /> -Attach complete plans(to the county copy only)for the system, on paper not less than S ATE PLAN I.D.NUMBER <br /> 8'h x 11 inches in size. <br /> -See reverse side for instructions for completing this application. P TITION <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. I F R VARIANCE ❑VES ❑ NO <br /> PRQ24RTYOWNER PROPERTY LOCATION <br /> �$4)Y. S/.l�'�a, S T , N, R 5- E (or W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVIS O NAME <br /> oat D N� Ns� ism �-y 1 io20 <br /> TY,STATE ZIP CODE PHONE NUMBER CITY NEAREST ROAD,LAKE OR LANDMARK <br /> UC I r V33 (� VILLAGE SW jSS /ems /CO <br /> II. TYPE OF BUILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family OZ 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 /> ystem 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 Brit to County Copy. <br /> IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2) <br /> 1. a.V Conventional b. El 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.15t Seepage Bed b. ❑seepage Trench c. ❑ Seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. TER SUPPLY: <br /> (Minutes p r inch): REQUIRED(Square Feet): PROPOSED(Squ a Feet): e. <br /> Feet vXllrivate ❑Joint ❑ Public <br /> CAPACITY <br /> VI. TANK in alions Total #of Prefab. Site Fiber- Exper. <br /> INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- St I glass Plastic App <br /> Tanks rTanks strutted <br /> Septic Tank or Holding Tank El <br /> Lift Pump Tank/Siphon Chamber Li ❑ <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): MP/MPRSW No.: B siness Phone Number: <br /> E- / ZrKZW <br /> 3aa <br /> � - 71 - a44-iso <br /> Plumber's Address(Street,City,State,Zip Code): Name of Designer: <br /> Rr 3 45g )e 470 <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name S715- <br /> # / <br /> /?oti,i)i- 7 E - Re Or T 6s <br /> CST's ADDRESS(Street,City,State,Zip Code) I e Num er: <br /> eT 3 60 7 L?9i l�1oL7� , Ak. 54x8 fl (f 0- 3 o <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> 'k7/� ❑ Disapproved Sa itary Permit Fee Groundwater ate Issuing A ent S gnature(No Stamps) <br /> l�,�Approved ❑ Owner Given Initial •i4T1 S Lc�haeF� �_ nJ <br /> / Adverse Determination 00 <br /> X. COMMENTS/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)F.03/86) DISTRIBUTION: Original to County.One Copy To:Bureau of Plumbing,Owner,Plumbe <br />