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:IRV, <br /> APPLICATION FOR SANITARY PERMIT� ILHR y' ^ e 'RUNTY <br /> (PL6 67) UNIFORM SANITARY PERMIT # <br /> OEPLROF <br /> Ir10lLiiBOR6MLlmiin RELHTIOnS <br /> —Attach complete plans in accord with s. H 63.05,Wis. Adm. Code for the system, on paper not less than 8Y x 11 inches in size. /1 <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> PROPERTY OWNER MAILING ADDRESS <br /> e 73/0 / <br /> PROPERTY LOCA ION CITY: <br /> 1/45j1/4, SoZ T%D, N, R /yE (or WSOW OF) S 0 <br /> LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD K OR LANDMARK STATE PL I.D. NUMBER <br /> GL J­ AIA eAIA <br /> TYPE OF BUILDING OR USE SERVED <br /> X 1 or 2 Family Number of Bedrooms: pZ, ❑ Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> New System ❑ Tank Replacement ❑ Repair <br /> Replacement Sail Absorption System ❑ Revision ❑ Privy <br /> ❑ Alternate System ❑ Reconnection ❑ Petition for Modification <br /> IF ,T�HfIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. <br /> I Seepage 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 Oc D <br /> Lift Pump Tank/Siphon Chamber OJ <br /> IV <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 Pumptu/Sipr:hon Chamber <br /> fa <br /> Manucre <br /> PERCOLATION RATE ABSORPTION AREAABSORPTION AREA WATER SUPPLY: <br /> (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): <br /> /9 L//Q X Private ❑ Joint ❑ Public <br /> I,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Name of P u ber (Print): Sig ture: • MP/MPRSW No.: Phone Number: <br /> cte fIC4 y- / C st 30110 <br /> 0 lir , ycs-dC�3 <br /> Plumber's Addre : Name of Deesl/�^er/�{ <br /> / o / ✓ 0 s /it/ r� /'/ / <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signature of Issuing Agent: I Fee: Date: ❑ Disapproved <br /> �jr da ❑ Owner Given Initial <br /> a3'tl� �LL y✓G yJ p d e7 '�0 �` Approved Adverse Determination <br /> iIWason for Disapproval: Fj <br /> Alternate course(s)of Action Available: <br /> Cl LHR-SBD 6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner,Plumber <br />