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W! HR SANITARY PERMIT APPLICATION1Zj <br /> In accord with ILHR 83.05,Wis.Adm.Code <br /> IO STATE SANITARY P&RMIT# <br /> C X1 <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.N BER <br /> 8'/z 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 /> PROPERT OWNER P.RfPPERTY LOCATION <br /> L lq� L N� '/aJW'/a, S:2k T39N, R � E ( <br /> PROPS TYOW ER'S ry11L. ING ADDRESS LOT NNUU,MMB -rBLOCK.NV BER SUBDIVISION_NAME <br /> Cl Y,STATE ZIP COD,CE^/ PH NE NUMBER CITY r(/ NEAREST ROAD,LAKE OR LANDMARK <br /> / H // VILLAGE : C O <br /> It. TYPE OF BUILDING OR USE SERVED: / 7 c �/�vAV�RvD <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. KConventional 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. ABSORP ION 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 5.SYSTEM ELEVATION 6. WATER SUPPLY: <br /> (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet). / "Feet Xprivate ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> I n allons Total #ot Prefab. Fiber- Exper. <br /> INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Se Tank or Holdin Tank _ <br /> Lift Pum Tank i hon Chamber ❑ ❑ ❑ <br /> V SPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for Ilation of the private sewage system show on the attached plans. <br /> Plumber's Name(Print): PI b r Si ture1No Sta PRSW No.: Business Phone Number: <br /> Ono 6�saiU -6 7is -y6s- <br /> Plumber's Address(Street,Cit State,Zip Code : Name of Designer: <br /> Z �srF <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name CST# <br /> X40& e1qED <br /> CST's DDRESS(Street,City,State,Zip Code) Phone Number: <br /> /�T Z 0 511D _52RLAI, W/S, sY a- /i <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee I Groundwater ate Issuing Agent Signature(No Stamps) <br /> Approved ❑ Owner Given Initial (X�11�1 ,,,,hhhU,,,,���� S char a�F�eerfee''�� <br /> Adverse Determination � "`�" I 11 <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 />