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SANITARY PERMIT APPLICATION c <br /> 7 fILHR In accord with ILHR 83.05,Wis. Adm. Code <br /> S ATE SANITARY P MIT# <br /> Q 141!2 <br /> –Attach complete plans(to the county copy only)for the system,on paper not less than S ATE PLAN I.D.NLTMSEIR <br /> 8'%x 11 inches in size. <br /> –See reverse side for instructions for completing this application. P TITION <br /> I. APPLICANT INFORMATION–PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑VES ❑ NO <br /> PROPERTY O/W ER PROPERTY LOCATION <br /> 0%vLq ( L . 8o4`rS PE '/aS',E '/a, S o27 T V1N, RIS— R(or) W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVIS ON NAME <br /> s �3 S'`i nJc7' �.Qh 'e- PA ✓A v <br /> CCIITY,STATE // ZIP CODE PHONE NUMBER CITY NEAREST ROAD,LAKE OR LANDMARK <br /> ^Wtr FR[LP Wt/. a ❑ VTOWN ILLAGE ; Swldrs L.Q, 'C oZ6 <br /> If. 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,if applicable) <br /> 1. a. El New b. IJ 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. © seepage Bed b. ❑Seepage Trench c. ❑ seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 15.SYSTEM ELEVATION 6. W TER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): e7 <br /> �+ /0 7 �. �S/ Feet ®F rivate ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in gallons Total #of Manufacturer's Name Prefab. Con- Ste I Fiber- plastic Exper. <br /> INFORMATION New xisting Gallons Tanks Concrete glass App. <br /> Tanks Tanks structed <br /> Septic Tank or Holding Tank X 7S e 1 7` 14 C ❑ ❑ <br /> Lift Pum Tank/Siphon Chamber ,{` p /—t C_ L1 11 <br /> VII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plan <br /> Plumber's Name(Print): Plum 's Signature:(No Stamps) MP/MPRSW No.: B 1.siness Phone Number: <br /> if e th r 63 It s% /.r- 6k YIP <br /> Plumber's ppddres (Street,City,State,Zip Code): Name Desi ner: <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name CST# <br /> i rrC� 0 KT Y� <br /> CST's ADDRESS(Street,City,State,Zip C de) Phone Number: <br /> w 6 r 7`—l— ..a` . s s - ir7 <br /> IX.1 COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee Groundwater ate Issuing Agent Si nature(No Stamps) <br /> Approved ❑ Owner Given Initial QQ (!;c Surcharge Fee <br /> Adverse Determination "O' " <br /> X. 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 />