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iimm Wisconsin APPLICATION FOR SANITARY PERMIT <br /> &ZWe-e-ee' COUNTY <br /> DILHR (PLB 67) <br /> - OEPARTRIEnT OF UNIFORM SANITARY PERMIT# <br /> ill IfOUSTRV,LABOR 6 HUTRn RELRTIOns ,5,7, 5..s" / ,, / <br /> —Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8Y2x 11 inches in size. <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> PROPERTY OWNER MAI ING ADDRESS <br /> PROPERTY LOCATION -etfi-': <br /> ;=: <br /> Sl.V1/4A) /4, S 39 % � <br /> , TN, R � ® (or) W TOWN OF: fC4- u". <br /> LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER <br /> J O ) 0 N A G5=,-,-1-,., L.,k/'S-e <br /> TYPE OF BUILDING OR USE SERVED <br /> Z 1 or 2 Family Number of Bedrooms: a- ❑ Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> ❑ New System Cl Tank Replacement ❑ Repair <br /> M. Replacement Soil Absorption System ❑ Revision ❑ Privy <br /> ❑ Alternate System ❑ Reconnection ❑ Petition for Modification <br /> IF THIS ISA CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. <br /> • Seepage Bed ❑ Seepage Trench Cl Seepage Pit ❑ Holding Tank <br /> J System-In-Fill Cl In-Ground Pressure ❑ Vault Privy q ❑ Pit Privy <br /> xExisting, For Which A Previous Permit Is On File, Permit #1//5-.2 ( 9/4/2) issued / -/r- iG - <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 —7.5-0 / ..----- <br /> Lift <br /> Lift Pump Tank/Siphon Chamber <br /> Holding Tank capacity <br /> Manufacturer: (/d <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): PROPOSED (Square Feet): <br /> 3 4j/ 0 4 3 )- X.Private ❑ Joint ❑ Public <br /> I,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> N e of Plum er Si ure: )4...pli)2A.:%. MP/MPRSW No.: Phone Number: <br /> KO ` p (Pri t): i s <br /> Plumber's Address: Name of Designer: • <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signature of Issuing Agent: Fee: Date: ❑ Disapproved <br /> 11Owner Given Initial <br /> Q:4,"7/7 1/4-/Zqq.A.) oi r/ Approved Adverse Determination <br /> Ryason for Disapproval: / X) <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 />