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E=7.- I L H R APPLICATION FOR SANITARY PERMIT <br /> � COUNTY <br /> (PLB 67) <br /> wt 'E"T oc UNIFORM SAN TARY PERMIT # <br /> srra�.Lraaow na�nnons / O/J n M/� / ^� <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 inchesinsize. `/ J <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> PROPERIA OWNER MAILING ADDRESS _ <br /> , eta9 <r^ p?$� r li/ <br /> PROP TY LO ATION V591 -CITY I <br /> /4 /4, S O. T N, E (or V w GF illt <br /> L UMRER BLOC NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LAN MARK STATE PLAN I.D. NUMBER <br /> i <br /> TYPE OF BUILDING OR USE SERVED <br /> ;id-1 or 2 Family Number of Bedrooms. ❑ 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 Pit �Holding Tank <br /> El System-In-Fill ❑ In-Ground Pressure Ll 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 <br /> Gallons Tanks Concrete Constructed Steel Fiberglass Plastic <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 Feet): PROPOSED (Square Feet): <br /> Private ❑ Joint ❑ Public <br /> I,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Name Plumber (Print : Signatur MP/MPRSW No.: Phone Number: <br /> PI mXr's Address IName of Designer: <br /> r ~ <br /> C TY/DEPARTMENT USE ONL <br /> Signature of Issuing Agent: Fee: Date: ❑ Disapproved <br /> Go c ❑ Owner Given Initial <br /> �yryQp� S /J O� Approved Adverse Determination <br /> ason for Disapproval: X-V <br /> Alternate course(s)of Action Available: <br /> DILHR-SBD 6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner, Plumber <br />