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LJ WD 1 L H R APPLICATION FOR SANITARY PERMIT <br /> "�'- �� COUNTY <br /> oeRmTmem OF (PLB 67) UNIFORM SANITARY PERMIT# <br /> mousTc ,,I-ReaR s Humnn weI.wTions <br /> —Attach complete plans in accord with s. H 63.05, Wis.Adm. Code for the system, on paper not less than 8/zx 11 inches in size. <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> PROP ERTV 9WNER MAILING ADDRESS , <br /> rc d 4 J <br /> PROPERTY LOCATION CITY: ��- <br /> VW1/4ME1/4, S , T QN, R /f M (or) W TOWN OF S CQ <br /> LOT NUMBER BLOCK NUMBER SUBDIVISION NAME p EST ROAD, LAKE OR LAN9MARK STATE PLAN I.D. NUMBER <br /> 3 11 4U <br /> TYPE OF BUILDING OR USE SERVED <br /> 1 or 2 Family Number of Bedrooms: 7.-- T Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> X 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 /> nid 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 7 S 0 1 X <br /> Lift Pump Tank/Siphon Chamber s 0 <br /> Holding Tank capacity <br /> Manufacturer: L'y C-10 <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/$i ph on Chamber <br /> Manufacturer: <br /> PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: <br /> (Minutes per inch): REQUIRED (Square F ) I PROPOSED (Square Feet): <br /> �jqt 7 Private ❑ Joint ❑ Public <br /> I,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> N of P/umber (Pri 1: Sig � MP/MPRSW No.: Phone Number: <br /> a dam , l « 6 3 in s-9 7ir) X66-v� <br /> Plumber's V �p N eof 2esigner: , <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signature of Issuing Agent: FQe: Date: ❑ Disapproved <br /> ' c�' r\ _ . ❑ Owner Given Initial <br /> du " '> „'.-',�7.Y/,. „'-' Approved Adverse Determination <br /> ason for Disapproval: /C/ <br /> Alternate course(s)of Action Available: <br /> DILHR-SBD 6398 (R. 5/82) DISTRIBUTION: Original to County. One Copy To; Bureau of Plumbing,Owner,Plumber <br />