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w �^�^ APPLICATION FOR SANITARY PERMIT <br /> DILHR �E` COUNTY <br /> (PLB 67) UNIFORM SANITARY PERMIT# <br /> nMST rnEnT OF <br /> � R1IX15TRV.LfiBIXi6HUTPn RELRT10n5 ��� �� ����� ) <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 inches in size. <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> PROPERTY OWNER MAILING ADDRESS _ <br /> LUc 0 Wec J rH Sl�rc SS v' rf <br /> PROPERTY LOCATION C Y: , <br /> NN-1 114SW1/4, Std , T N, R / IF (or) W TOWN OF C1 h O h- <br /> LOT NUMBER BLOCK NUMBER SUBDIVISION NAME ST ROAD, �J,ORLANDMARK STATE PLAN I.D. NUMBER <br /> TYPE OF BUILDING OR USE SERVED <br /> W1 or 2 Family Number of Bedrooms: ❑ Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> ❑ New System .9� Tank Replacement ❑ Repair <br /> 'd Replacement Soil Absorption System ❑ Revision ❑ Privy <br /> ❑ Alternate System ❑ Reconnection ❑ Petition for Modification <br /> IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. <br /> Seepage Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holding Tank <br /> J 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 Feetl: PROPOSED (Square Feet): <br /> JR@phjll <Joint ❑ Public <br /> I,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> N;p of P.1 ber (Prin ): Sig re - MP/MPRSW No.: Phone Number: <br /> r C7 SC-ue vn/a G 3 (` tq <br /> r7t&- ) b'6( q/J <br /> Plumber's A r Nam Design r: <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signature of Issuing Agent: Fee: Date: ❑ Disapproved <br /> � 00 <br /> El Owner Given Initial <br /> !In/ n � AOp 5f — 'pS Approved Adverse Determination <br /> Mason for Disapproval: ICJ <br /> Alternate course(s)of Action Available: <br /> DILH R SBD 6398 (R.5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner, Plumber <br />