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u w' APPLICATION FOR SANITARY PERMIT � <br /> L.� COUNTY <br /> D I L H R <br /> (PLB 67) <br /> T OF UNIFORM SAN ARY PERM # <br /> pEPRRTTEI'1 <br /> aaaaaaaaa� IIIOUSTRV,LRBOR&HUraRn RELRTIonSt <br /> 16— <br /> —Attach complete plans in accord with s. H 63.05,Wis. Adm. Code for the system, on paper not less than 8%x11 inches in size. / <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> P5.0PERTY OWNER / MAILING A�DpDRE S <br /> J Q W'1 t 1 �'-� @-e r S O �l� K f f J 0 G � Bc, r <br /> PROPERTY LOCATION CITY: —�— <br /> S£ 1/4IVE'1/4, S /S , TVN, R /rJI (or) W KowN o ✓ /f`.ro �� <br /> LOT` UMBER BLOCrK`NU IBER SUBp'IIVVISIO ' AR EST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER <br /> TYPE OF BUILDING OR USE SERVED 6/ <br /> X 1 or 2 Family Number of Bedrooms: ❑ Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> e 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 /> Z 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 O V <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. Steel Fiberglass Plastic <br /> Gallons Tanks Concrete ConstruSite cted <br /> Septic Tank Capacity <br /> Lift Pump/Siphon Chamber <br /> Manufacturer: <br /> PERCOLATION RATEABSORPTION AREA ABSORPTION AREA 1/t1ATER SUPPLY: <br /> (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): <br /> b (O/ S (P 7 o Private ❑ Joint ❑ Public <br /> I,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> N e of Plumber (Priv )'. Si e: MP/MPRSW No.: Phone Number: <br /> op't <br /> Plumber's ddres : ��. NprR�4si ec <br /> K7 COUNTY/DEPARTMENT USE ONLY(`/O <br /> Signatur Issuing Agent: Fee: Date: ❑ Disapproved <br /> (JCS �[ ❑ Owner Given Initial <br /> U Approved Adverse Determination <br /> Rea f r Disapproval: <br /> Alternate courses)of Action Available: <br /> DILHR SBD-6398 (R.5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner, Plumber <br />