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APPLICATION FOR SANITARY PERMIT <br /> � DILHROUNTY <br /> (PLB 67) <br /> UNIFORM SANITARVP RMIT= <br /> a'a 77? (/i3y9� <br /> —Attach complete plans in accord with s. H 63 05, Wis.Adm. Code for the system,on paper not less than 89:x 11 inches in size. <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> PROPERTY OWNER MAILING ADDRESS yj t/J ka <br /> 1i J 4JM n.t 4v90 i-re s:sior 1109 3'/ 'co.., r7.vV r1/.v <br /> PROPERTY LOCATION CITY'. <br /> VILLAGE: �j k <br /> .w 1/4.9w 1/4, S ,v , T39, N, R/ii 1 (or) W ITOWNOF: <br /> LOT NUMBER I BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D.NUMBER <br /> / T k, F{ Q <br /> TYPE OF BUILDING OR USE SERVED <br /> iX) 1 ort Family Number of Bedrooms: 2 J Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> % New System J 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 /> Wi Seepage Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holding Tank <br /> J System In Fill J IrvG tau nd Pressure ❑ Vault Privy ❑ Pit Privy <br /> ❑ Existing, For Which A Previous Permit Is On File,Permit = issued <br /> J An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions. <br /> TInal =atPrefab. Site Steel Fiberglass Plastic <br /> Gallons Tanks Concrete Constructed <br /> Septic Tank Capacity 5 O <br /> Lift Pump Tank/Siphon Chamber <br /> Holding Tank capacity <br /> Manulamurer. <br /> IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound [] InGroundPressure <br /> Total -of Prefab. Site Steel Fiberglass Plastic <br /> Gallons Tanks Concrete ConnructeJ <br /> Septic Tank Capacity <br /> Litt PumplSiphon Chamber <br /> ManuNa <br /> PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: <br /> (Minutes per inch: REOUI R ED (Square Faatl: PROPOSED (Square <br /> Feetl: <br /> e//0 J Private L Joint ❑ Public <br /> I,the undersigned,hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Name of Plumber IPrim1: Slgnat ere: MP/MPRSW No.: Phone Nutnbcr: <br /> W .A(S WQ `/Y/7 163x1' 2vf�7 <br /> Plumber's Address Name of Designer: <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signature of Issuing Agent Fee: <br /> D"', <br /> pate%: <br /> 11 Oveei ive <br /> n Inital <br /> App.nytl Adverse <br /> de s�Diererminan <br /> on <br /> Reason for Disapproval: <br /> Alternate courodsl of Action Available: <br /> DILHR Son.63981 R.6/931 DISTRIBUTION: Original le County, One Copy To; Bureau of Plumbing,Owner, Plumber <br />