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�_�^�^ APPLICATION FOR SANITARY PERMIT <br /> DILHR p ✓,,,�,��, <br /> OUNTY <br /> E7�7 <br /> 1EnT OL 1('LU 67) UNIFORM SANITARY PERMIT # <br /> IXISTRV,LMOR&HURYin RELRTIOnS _ <br /> —Attach complete plans in accord with s. H 63.05, Wis.Adm. Code for the system, on paper not less than 87zx 11 inches in size. <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> PROPEF/}TY OWN R MAILING ADDRESS * ,///1 <br /> PROPERTY LOCATION <br /> W 7/4 5 1/4, S T N, R / (or) IN TOWN h / 0 i� <br /> LOT NUMBER BLOCK NUMBER SUBDIVISI N NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER <br /> N� ti' Al N I ZZY <br /> TYPE OF BUILDING OR USE SERVED <br /> X1 or 2 Family Number of Bedrooms: �3 ❑ 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 /> IV 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 <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 Fat): PROPOSED (Square Feet): <br /> Ir I (0/, S— �( O 59 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): Si e: MP/MPRSW No.: Phone Number: <br /> der ft c - IS(nS 0'f' d Sit -�I- y I ()/T)f66 <br /> Plumber's A ress: Name of Designer: <br /> W W1. <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signet of Issuing A en Fee: Date: ❑ Disapproved <br /> �j�� ❑ Owner Given Initial <br /> �K� .ai%ZG'/L��� tip ✓ �� /,.)- X � Approved Adverse Determination <br /> son for Disapproval: IX <br /> r <br /> Alternate courses)of Action Available: <br /> DILHR SBD6398 (R.5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner,Plumber <br />