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u„=cons,n APPLICATION FOR SANITARY PERMIT <br /> ( IDILHF -COUNTY <br /> (PLB 67) UNIFORM SANIT Y PERMI # <br /> ill.RT mEIIT OF ` '^ <br /> OUSTgV,LRBOg6MVTgr1RELRT10r15 �/ <br /> —Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8%x 11/iinches in size. /C <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> PROPER Y OWNER p MAILING ADDRESS b <br /> �4�v ru 1� e �r I66WSN /0 r4dna � ro� <br /> PROPERTY LOCATION CITY: �^� <br /> VI /T /I <br /> E 1/4 VW1/4, S 13 , T N, R / (or) W WN OF: �) Y <br /> LOT NUMBER BLOCK MBER SUBDIV ION NAME -7-- ST ROAD, LAKE OR LANA GARK� STATE PLAN I.D. NUMBER <br /> l N W y a s c� r Z r r r //� "/1r <br /> TYPE OF BUILDING OR USE SERVED <br /> ;1F1 or 2 Family Number of Bedrooms: U Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> New System ❑ Tank Replacement ❑ Repair <br /> ❑ Replacement Soil Absorption System ❑ Revision ❑ Privy <br /> ❑ Alternate System ❑ Reconnection ❑ Petition for Modification <br /> IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. <br /> y�;PSeepage Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holding Tank <br /> ❑ System-In-Fill ❑ In-Ground Pressure ❑ Vault Privy ❑ Pit Privy <br /> ❑ Existing, For Which A Previous Permit Is On File, Permit # issued <br /> ❑ An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions. <br /> Total of Prefab. Site Steel Fiberglass Plastic <br /> Gallons Tanks Concrete Constructed <br /> Septic Tank Capacity <br /> Lift Pump Tank/Siphon Chamber <br /> Holding Tank capacity <br /> Manufacturer: <br /> IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure <br /> Total #of Prefab. Site Steel Fiberglass Plastic <br /> Gallons Tanks Concrete Constructed <br /> Septic Tank Capacity <br /> Lift Pump/Siphon Chamber <br /> Manufacturer: <br /> PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: <br /> (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feetl: <br /> Private ❑ Joint ❑ Public <br /> I,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Na f Plu ber IPrint):L Signa re: ` MP/MPRSW No.: Phone Number: <br /> b erlo r) /gljr 0 3Q3 9 9/nAlli <br /> Plumber's Address: Name Desig er: <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signat a of Issuin ent: Fge: Q Date: ❑ Disapproved <br /> (J� - /� Q ❑ Owner Given Initial <br /> Approved gdverse Determination <br /> on for Disapproval <br /> Alternate courses)of Action Available: <br /> DILHR-SBD-6398 (R.5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner,Plumber <br />