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(� SANITARY PERMIT APPLICATION COU TY <br /> U flLHR In accord with ILHR 83.05,Wis.Adm. Code u I n <br /> STATE SAN ITARY PEW IT#x� <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUKNVE <br /> 81/2 x 11 inches in size. <br /> sq <br /> —See reverse side for instructions for completing this application. PETITION <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ®YES ❑ NO <br /> PROPERTY OWNERA// PROPERTY LOCATION <br /> /a///4/'/a, S T , N, R 17 E (o ELW <br /> PROPERT, OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME <br /> 2/ !— <br /> CITY,STATE ZIP C DE PHONE NUMBER CITY NEAREST ROAD,LAKE OR LAND RK <br /> VILLAGE : �� ., <br /> 11. TYPE OF BUILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family�f 6(54011601115 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. ElReplacement 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. ❑Conventional b.oAlternative C. ❑ Experimental <br /> 2. a. ❑System- b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e.XMound f. ❑ IGP <br /> In-Fill Tank <br /> V. ABSORPTION SYSTEM INFORMATION: (Check one) <br /> 1. a. 0Seepage 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 IS ware Feet): <br /> I—T �5/ Feet Private ❑Joint L1Public <br /> VI. TANK CAPACITY Site <br /> in allons Total #of Manufacturer's Name Prefab. Fiber- Plastic Exper. <br /> INFORMATION New xisting Gallons Tanks Concrete Con- Steel glass App. <br /> Tanks Tanks T structed <br /> Septic Tank or Holding Tank GLZ7Z 0010 1 / ❑ X ❑ <br /> Lift Pump Tank/Si hon Chamber I Tm C— ❑ ❑ <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): Plumb is Signatur (No Stamps) MP/MPRSW No.: Business Phone Number: <br /> Plumber's Address(Street,City,State,Zip Code): �[�3 Name of Designer: <br /> o r l Ave. �. Po.,60 I <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Name CST# <br /> CST's DRESS(Street,City,State,Zip Code) Phone Number: <br /> COUNT /DEPARTM NT USE ONLYO C <br /> ❑ Disapproved Sanitary Permit Fee Groundwater Date Issuing ent Signature(No Stamps) <br /> Approved ❑ Owner Given Initial /ILI�I.i (� `SururcharuewF�(eee� <br /> Adverse Determination � ! r�9OD �$a-5.W <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 />