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L H R APPLICATION FOR SANITARY PERMIT <br /> f' COUNTY <br /> (PLB 67) UNIFORM SANI ARY PERM T # <br /> E: � <br /> 1EnT OF lWSTRV,IRBOF6MUTFnFlELnT1On5 /,'+fO-V/ <br /> —Attach complete plans in accord with s. H 63.05, Wis. A Im. Code for the system, on paper not less than 8'/zx 11 inches in size. <br /> —See reverse side for instructions for completing this app) cation. PLEASE PRINT <br /> PROPERTY OWNERTZ /-; A' �� ,4 MA I G ADDRESS ! C IfvlC <br /> PROPERTY Lf�1�ATION /ri crm: J <br /> /rte [,��../{,r �l WN OE: P <br /> (,O[�L'/Ij4 1/4, S , N, R TOWN OF: <br /> LOT NUMBER BLOCK NUMBER SU BDIVI ON NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER <br /> 3 /! Z ee 7 Siol, tix/�� <br /> TYPE OF BUILDING OR USE SERVED <br /> DO 1 or 2 Family Number of Bedrooms: 02 ❑ 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 HIS BLOCK. <br /> XSeepaye 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 /> Tot I #of Prefab. Site <br /> Gallo s Tanks Concrete Constructed Steel Fiberglass Plastic <br /> Septic Tank Capacity V' <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 /> Tot #of Prefab. Site Steel Fiberglass Plastic <br /> Gall ns Tanks Concrete Constructed <br /> Septic Tank Capacity <br /> Lift Pump/Siphon Chamber <br /> Manufacturer: <br /> PERCOLATION RATE ABSORPTION AREAABSORPTION AREA WATER SUPPLY: <br /> (Minutes per inch): REQUIRED (Square Feet): PROIS 1 POSED (Square Feetl: <br /> '41149 1 1e Private ❑ Joint ❑ Public <br /> I,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Narge,of Plu ber (PZ <br /> t): Si MP/MPRSW No.: Phone Number: <br /> P L4/P o /O?� (7/1) <br /> Plumber' Address: WDesig r: <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signature of Issuing Agent: Fee: Date: _❑ Disapproved <br /> F �s� Owner Given Initial <br /> j i 6 O (J Approved Adverse Determination <br /> son for Disapproval: F v <br /> Alternate course(s)of Action Available: <br /> DILHR SBD-6398 (R. 5/82) DISTRIBUTION: Original t County, One Copy To; Bureau of Plumbing,Owner, Plumber <br />