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......... APPLICATION FOR SANITARY PERMIT y <br /> � (PLB 67)DILHR f62- OUNTY <br /> UNIFORM SANITARY PERMIT <br /> �a7So ( //v/d <br /> —Attach complete plans in accord with s. H 63.05,Wis.Adm.Code for the system, on paper not less than 8Yhx 11 inches in size. <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> PROPERTY O NER MAILING AiIPPESS / , <br /> YPRO ERTV LOCATION CI <br /> VI AGE: "-,5r <br /> C/ 1- <br /> 1/4 1/4, S , T , N, R E (or oE. L/ J <br /> LOTNUMBER BLOCK N MBER SUBDIV SION NAME EST ROAD, LAKE OR LANDMARK ISTATE PLAN I.D.NUMBER <br /> 8 <br /> TYPE OF BUILDING OR USE SERVED <br /> r. 1 or 2 Family Number of Bedrooms: ❑ Public(Specify): <br /> THIS PERMIT IS FOR A: <br /> �e<New System J Tank Replacement ❑ Repair j <br /> J Replacement Soil Absorption System ❑ Revision ❑ Privy <br /> J Alternate System J Reconnection J Petition for Modification <br /> IF THIS ISA CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. <br /> J Seepage Bed J Seepage Trench J Seepage Pit old my Tank <br /> J System-In Fill ❑ If, Ground Pressure J Vault Privy Pit Privy <br /> J Existing, For Which A Previous Permit Is On File, Permit at issued <br /> J An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions. <br /> Total #of Prefab. Sire Steel Flborplass Plastk <br /> Galloi Tanks Con Constructed <br /> Septic Tank Cal <br /> Litt Pump Tank/Siouan Chamber <br /> Holding Tank capacity <br /> Manulacwrer. f <br /> IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound J In Ground Pressure <br /> Total #pf Prefab. Site Steal Fiberglass Plastic <br /> Gallons Tanks Concrete Constructed <br /> Septic Tank Capacity <br /> Lit, Pump/Schon Chamber <br /> Manufacturer. <br /> PERCOLATION RATE ABSOR PTI ON AREA ABSORPTION AREA WATER SUPPLY: <br /> (Minutes per inch): REQUIRED (Square Feet): PROPOSED(Square Feet): <br /> rivate J Joint ❑ Public <br /> I,the undersigned, hereby assume responsibility for installation of the private sewage systen shown on the attached plans. <br /> Name of P tuber (Print): MP/MPRSW NoNumber::.: Phone Ner: <br /> Signature: <br /> Plumb r' tltlr a Name of De ig er. <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signature of <br /> na/ Issuingg Agent <br /> /ngo h.c ♦r : D6ate-:/� 11❑ DivveprGoivveein <br /> Initial <br /> O - � ;�Q a Adverse <br /> Determination <br /> ra,son for Disapproval: F. <br /> Alternate coarses)of Action Available: <br /> 011118 SBD 639818,5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner,Plumber <br />