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APPLICATION FOR SANITARY PERMITED- : <br /> ILHR (PLB 67) OUNTY <br /> ITmEnT OF UNIFORM SANITARY PERMI # <br /> TRV.LRBbR6MUTRn RELRT10n5 133 <br /> —Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 81/:x 11 inches in size. <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> PR6f RTY OW ER MAILING A RE <br /> PROPERTY LOCATION CITY: <br /> SW 1/4 PE1/4, S 3ST, T YUN, R 161 (or) W TOWN OF D o � � 0 H <br /> LOT NU BER BLOCK NUMBER SU BDIVI ON NAME EST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER <br /> N u/A N/ I 0 0 0V w o r t 40-4'< R <br /> TYPE OF BUILDING OR USE SERVED <br /> X 1 or 2 Family Number of Bedrooms: T Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> 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 /> ❑ Seepage Bed ❑ Seepage Trench ❑ Seepage PitHolding 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 Q e 0 <br /> Manufacturer: <br /> IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure <br /> Tota' <br /> #of Prefab. Site Steel Fiberglass Plastic <br /> Gallons Tanks Concrete Constructed <br /> Septic Tank Capacity <br /> Lift Pump/Siphon Chamber <br /> M ufacturer. <br /> ERCOLATION RATE ABSORPTION AREA SORP WATER SUPPLY: <br /> (Minutes per inc REQUI a eet): PROPOSED (Square Feet): <br /> ❑ Private El Joint El Public <br /> I,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> N e of lumber`Prl: Si re: t , MP/MPRSW No.: Phone Number: <br /> Plumber's Address. VNa f D igner: <br /> !KcQil <br /> COUNTY/DEPARTMENT USE ONLY <br /> Sign re of Isui Agent:sFee: a Date: <br /> //—� Disapproved <br /> a ❑ Owner Given Initial <br /> y Approved Adverse Determination <br /> ason for Disapprov . <br /> Alternate courses)of Action Available: <br /> DI LHR-SBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner,Plumber <br />