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C_^sI^ APPLICATION FOR SANITARY PERMIT 4— <br /> .� D I L H R rh SANITARY <br /> COUNTY <br /> a� oEwaRrmenr oc (PLg 67) UNIFORM SANITARY PERMIT # <br /> - inDUSTRV,LRBOR 6 HUTRn RELRTI0115 <br /> 7930 <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 /> PRO ERTV OWNER �^ MAILING ADDRESS <br /> CS V. lrrC 1 ��On <br /> 3-71.) xru /-euoe ✓e YT IOC'es S'Sl <br /> PROPERTY LOCATION CITY: <br /> 'SO/4'3W 1/4, S-31l , T3?, N, R /s�-fer VIL GE: <br /> LOT NU(�1BER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD,4aKpOR LANDMARK STATE PLAN I.D. NUMBER <br /> I t <br /> TYPE OF BUILDING OR USE SERVED <br /> 1"'I 1 or 2 Family Number of Bedrooms: 3 T❑ Plbl ic (Specify): <br /> THIS PERMIT IS FOR A: <br /> X 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 /> X 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 QQ(•f <br /> Lift Pump Tank/Siphon Chamber <br /> Holding Tank capacity <br /> Manufacturer: iAJ!ies ev cxc r-' tv; <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 SUPPLY: <br /> (Minutes per inch): REQUIRED (Square Feet): PRO <br /> POSED <br /> '((Square Feet): <br /> 3 _3 S (p ) 7 Private ❑ Joint ❑ Public <br /> I,the undersigned, hereby assume responsibility for in Ilation of the private sewage system shown on the attached plans. <br /> Name of Plumber (Prin ): Signatu� � ///� MP/MPRSW No.: Phone Number: <br /> Plum er's Address: Name of Designer: <br /> v e bSf'or- IS 5 m3 N l S k�ij r` <br /> COUNTY/DEPARTMENT USE ONLY <br /> Si net a of Issuln Agent: Fee: Date: ❑ Disapproved <br /> 00 <br /> �]��� ���� _a7� ❑ Owner Given Initial <br /> yy Approved Adverse Determination <br /> son for Disapprov <br /> Alternate coursels)of Action Available: <br /> DILHR SBD6398 (R.5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner,Plumber <br />