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D I L H R APPLICATION FOR SANITARY PERMIT <br /> COUNTY <br /> (PLB 67) UNIFORM SANITARY PER IT # <br /> - f1EPRRTTEITT OF <br /> Ir1IXJ5TRV,LRBOR 6MURIRrI RELRTlOr15 / / <br /> —Attach complete plans in accord with s. H 63.05, Wis.Adm. Cade for the system, on paper not less than 81/zx 11 inches` in size. <br /> —See reverse side for instructions for completing this application. <br /> Ql/lP,LEAITSE PRINT <br /> POPL' TYhWCCTR ,IN^ ADDRESS S `7 9 / or <br /> PROPERTY LOCATION CITY: .S <br /> 1/4.Sw1/4, S /� , TYq N, R 4 ■ (or) WTOWN OF: O4 �li A <br /> LOT N MBER I BLOCK NUMBERSUBDIVISION NAME ST ROAD, LA E O/R LANDMAR�K STATE PLAN I.D. NUMBER <br /> Al�Pt V &OM1 �U rr r r "r Iq d Zlil aG., <br /> TYPE OF BUILDING OR USE SERVED <br /> 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 /> 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 I x <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. Siteteel Fiberglass Plastic <br /> - <br /> Gallons Tanks Concrete Constructed S <br /> Septic Tank Capacity <br /> Litt Pump/Siphon Chamber <br /> Manufacturer: <br /> PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA N/gTER SUPPLY: <br /> (Minutes per inch): REQUIRED (Square Feetl: PROPOSE (Square Feet): <br /> .S els I Y1 Private ❑ Joint ❑ Public <br /> I,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Ng ofP�`'tuber (Print): / Si e: , MP/MPRSW No.: Phone Number: <br /> Plumber's A dress: Na f Desig r. <br /> COUNTY/DEPARTMENT USE ONLY <br /> Si nature of Issuing Agent: Fee: Date: ❑ Disapproved <br /> pq Oc <br /> Approved Owner Given Initial <br /> Adverse Determination <br /> eason for Disapproval: <br /> Alternate courses)of Action Available: <br /> DI LHR-SBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner,Plumber <br />