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WSCO^=^ APPLICATION FOR SANITARY PERMIT <br /> 'r DILHR COUNTY <br /> (PLB 67) UNIFORM SANITARY PER IT # <br /> pEPfiRTTEIIT OF <br /> IrrOUST V,LRBOFl 6 HUTPr1 FELFT10n5 /� , <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 /> PROPERTY OWNERy,�I / MAILING ADDRESS e9 <br /> �h0 n /CS �T F'1 C/O-P rJ S 9 1 <br /> PROPERTY LOCATION I CITY: <br /> SE 1/4SE1/4, S c27 , TAN, R/7 v (or) W 41TOVVN OFJ Lite n i 4 1' <br /> LO:NUMBER I BLOCK NUMBER ISUBDIVISION NAME S RZS,LAKE OR LANDMARK STATE PLAN I.D. NUMBER <br /> TYPE OF BUILDING OR USE SERVED ,N'r a/ /pei/ <br /> L�1 or 2 Family Number of Bedrooms: ❑ Public (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 /> 9 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 .T V <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 /> Litt 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 /> 3 <//0 7 � eZ I X Private ❑ Joint ❑ Public <br /> 1,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Na Plumber (Print): Sigaa(iire: _ /� MP/MPRSW No.: Phone Number: <br /> • e ,�' o �"fyc V` s`dvl. `.� 7CL d30p Plumber's dr - Name of Designer: <br /> S' <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signa re of Issum Agent- Date: ❑ Disapproved <br /> p <br /> _ po ` ❑ Owner Given Initial <br /> /d-7'�d Approved Adverse Determination <br /> son for Disapprov . <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 />