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iiimm wl5con51n APPLICATION FOR SANITARY PERMIT '{� <br /> .DI L H R 43" COUNTY <br /> - OEPRRTTEBT OF ���� ��) UNIFORM SANITARY PERMIT# <br /> - IOOUSTRV,LRBOR 6 HUTRB RELRTIOfS <br /> —Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 81/2x 11 inches in size. <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> PR ERTY OWNER MAILING ADDRESS <br /> PROPERTY LPCATION CITY: / <br /> U J/4 .-' 1/4, S 13, TI iN, R /7 L (or) W vlwNOF;- 4 I 'tj ' 4 ,,_ <br /> LOT NUMBERBLOCK NUMBER SUBDIVISIQN NAME -R Esj ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER <br /> TYPE OF BUILDING OR USE SERVED <br /> i 1 or 2 Family Number of Bedrooms: s-. ❑ 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 /> Ie 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 '7S L; I X <br /> Lift Pump Tank/Siphon Chamber <br /> Holding Tank capacity <br /> Manufacturer: IL /1.4 (--- <br /> I F <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 /> 4/l 0 el Private LJ Joint ❑ Public <br /> I,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> romber )PrI <br /> v ): Si re: MP/MPRSW No.: Phone Number: <br /> ell % i '"," t.,\.,Q,- l' ' A \ C Cs. C- <br /> t. <br /> Plumber's Adss: Name f Designer: <br /> Li .4_,64---- - c_d'..2. �� •s- gr ri <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signature of Issuing Agent: Fee: Date: <br /> Disapproved <br /> v ) / O�' El Owner Given Initial <br /> a j-jed,v74,14' <br /> -I,!/ ,‘ C.0 - <br /> - <br /> P--/ Approved Adverse Determination <br /> vasa,-„zed <br /> for Disapproval: <br /> Alternate coursels)of Action Available: <br /> DILHR-SBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner, Plumber <br />