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==Z <br /> APPLICATION FOR SANITARY PERMITHR COUNTY <br /> (FLB 67) UNIFORM SANITARY PERMIT # <br /> &HUmRnRElRTions <br /> 0/17 (11Z16 <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 /> PR P RTY OWNER MAILING ADDRESS <br /> v e W LU <br /> P OPERTY LO ATION CITY: ''�� <br /> U)1/4S 1/4, S , T N, R /s (Or) W TOWN OF. t/ 4 c 1 v <br /> LOT NUMBER BLOCK ANUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER <br /> M- L, 0 W PJ' LQ C r1 L,4 <br /> TYPE OF BUILDING OR USE SERVED <br /> ;A 1 or 2 Family Number of Bedrooms: ' ❑ Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> 9 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 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 S` V <br /> Lift Pump Tank/Siphon Chamber <br /> Holding Tank capacity <br /> Manufacturer: A4 C_ <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 $U PPLY: <br /> (Minutes per inch): REQUIRED (Square Feetl: PROPOSED (Square Fee fl: <br /> at 0 S- Private ❑ Joint ❑ Public <br /> 1,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Na of P}}umber (Print): $i e: � � � � MP/MPRSW No.: Phone Number: <br /> 0d —p s R k o3as � 7i��6bS/"s7 <br /> Plumber's Addre Na f D igner. <br /> COUNTY/DEPARTMENT USE ONLY <br /> Sign re of Issuin Agent: Fee: Date: ❑ Disapproved <br /> d° <br /> 4f p�i ❑ Owner Given Initial <br /> A <br /> O / / pproved Adverse Determination <br /> ason for Disapproval: <br /> Alternate courses)of Action Available: <br /> DILHR-SBO-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner, Plumber <br />