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^='^ APPLICATION FOR SANITARY PERMIT <br /> 1: <br /> ILHR MS OUNTY <br /> (PLB 67) UNIFORM SA ITARY PERMIT# <br /> T V.LR OF 1 <br /> TRV,LRBOn 6MUTRrtRELRT10r15 <br /> —Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8/zx 11 inches in size. <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> PROPERTY rNER MAILING ADDRESS <br /> �yc �L r <br /> ` S <br /> PROPERTY LOCATION CITY: <br /> ()W1/41�1411/4, S /j , T �, N, R (or) W TOWN of Y S" <br /> LOT NUMBER BLOCK NUMBER SUBDIVISION NAME A ST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER <br /> /{ Nf� 1C//� e Q/ G <br /> TYPE OF BUILDING OR USE SERVED <br /> W 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 /> 19 Seepage Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holdiny 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 j Fiberglass j Plastic <br /> Gallons Tanks Concrete Constructed <br /> Septic Tank Capacity <br /> Lift Pump Tank/Siphon Chamber <br /> Holding Tank capacity <br /> Manufacturer: 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 tAJATER SUPPLY: <br /> (MiKes per inch): REQUIRED (Square Feet): P/y�ROOPOSED (Square Feet): <br /> y o 4 3 )�_ Private ❑ Joint ❑ Public <br /> I,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Wine'e off lumber (Xrpt). Si re: MP/MPRSW No.: Phone Number: <br /> /l aJ.,IC N k,' s a 3 o s p 7�r �6e .s <br /> Plumber's A ress: INpot Designer: , <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signa re of Issuing Agent: Fee: Date: ❑ Disapproved <br /> (�S d ❑ Owner Given Initial <br /> Approved Adverse Determination <br /> son for Disapprova . <br /> Alternate course(s)of Action Available: <br /> DI LHR-SBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner, Plumber <br />