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Wisconsin APPLICATION FOR SANITARY PERMIT /. <br /> D' L H R COUNTY <br /> (PLB 67) <br /> e� 1n0UST Y,LR oc UNIFORM SANITARY PERMIT# <br /> moustwv,�weoB swumwnr»=uaTrons <br /> X0063 () //. 7V) <br /> —Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'/sx 11 inches in size. <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> P PARTY OWNER Mp,IL NG ADD SS W <br /> It - ST A p�ES Mg <br /> fA R P6t - W � <br /> PROPERTY LOCATION CITY. <br /> .VV 1/4 9F 1/4, S 3s , TNI. N, R! /o E (or) OWN D :: 0 I <br /> LOT NUMBER BLOCK NUMBER SUBDIVISION NAME EST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER <br /> TYPE OF BUILDING OR USE SERVED <br /> ear 2 Family Number of Bedrooms: 3 ❑ Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> E!1"NeW System ❑ Tank Replacement ❑ Repair <br /> ❑ Replacement Soil Absorption System ❑ Revision ❑ Privy <br /> 1 Alternate System ❑ Reconnection ❑ Petition for Modification <br /> IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. <br /> N <br /> 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 <br /> Gallons Tanks Concrete Constructed Steel Fiberglass Plastic <br /> Septic Tank Capacity 0 <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 /> s Tanks Concrete Constructed <br /> Septic Tank Capacity Gallon <br /> Lift Pump/Siphon Chamber <br /> Manfac <br /> uturer: <br /> PERCOLATION RATE ABSORPTION AREA ABSORPTION ARE9WATER SUPPLY:(Minutes per inch): REQUIRED (SquareFeetl: PROPOSED ($quare Fe ,i,/ <br /> 4_ `/"-' L� 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 Plumber�(Print). Signature: MP/MPRSW No.: Phone Number: <br /> /7✓1 EN �C o s j rsr� oe°tns; J35'9+�zdG 9 <br /> Plumber's Address:y��7 �I _ Name Designe . <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signetur of Issuing q nt Fee: J Date: ❑ Disapproved <br /> k( <br /> 1:1 Owner Given Initial <br /> (�/ a %Approved Adverse 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 />