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umeiii wlsconsln APPLICATION FOR SANITARY PERMIT ,� <br /> ict DIL. I—IR 2Ge-s -""`rj COUNTY <br /> IMI Tn <br /> DEPRFITET OF (PLB 67) UNIFORM SANITARY PERMIT# <br /> - InousTRV,LRBOR&RUTRn RELPTIOns 5C2 76/ (//V3 <br /> �� <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 /> PROPERTY OWNER MAILING ADDRESS (. ]� <br /> a c'04 so fes\ / cC r- -O P L A:" r-- <br /> PROPERTY LOCATION CITY: <br /> PA)1/411 1/4, S 31-, TyoN, R /f 5 (or) W TOWN OF: J CT- Q <br /> LOT N�MBER BLOCK,NUMBER SUBDI�ION NAME =1vt�4ST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER <br /> Al <br /> TYPE OF BUILDING OR USE SERVED E/7 [/ <br /> V 1 or 2 Family Number of Bedrooms: a ❑ Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> igl 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 /> N.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 —2 S 0 1 x <br /> Lift Pump Tank/Siphon Chamber <br /> Holding Tank capacity <br /> Manufacturer: 7-Al 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 /> 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 /> 4P 7l L" T •. I Private ❑ Joint ❑ Public <br /> I,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Nae of lumber (Print): Sign "MP/MPRSW No.: Phone Number: <br /> do4.ViNiC k l�`cp iir4 S. 4 v--1 v C5 c% ('is)f66._&frJ7 <br /> Plumber's Ad ress: Name of Designer: <br /> k-A-Y k."..;\.)1-4---(,. *S--.ifir f .. k l'47-A—t" --a <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signature of Issuing Agent: z, Fee: Date: <br /> ��jj' p / r Disapproved <br /> :4eir <br /> ,,,-eta . )' / 0 ~ Approved LI Owner Given InitialG�"� J, �7 �D � Adverse Determination <br /> ason for Disapproval: r4., <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 />