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iminimm • <br /> wls`onson APPLICATION FOR SANITARY PERMIT <br /> ciy <br /> .D.ILHRGG`� COUNTY <br /> (PLB 67) <br /> - DEPRRTTEfIT OF UNIFORM SANITARY PERMIT# <br /> IMINI IfIOUSTRV,LRBOR 6 HUTRfl RELRTIOfIS <br /> , --p72i (/lY.7s <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 /> LD 'VS- S4 13,"4 (r 0,vrI f C_/c /O/1/ \S' I/4 i' 7'<'14 S fi 0("Abe v. __i r J y c'., i <br /> PROPERTY LOCATION CITY: <br /> VILLAGE: ��� ��" <br /> /C//= 1/4iyc .,1/4, S .tet , Tgo, N, Riy It (or) W :,aininF: <br /> LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER <br /> .-i 13`Y3 -S'' !i17iYi)iOAi _ 3 Q ii y, I-- 14it"-''- <br /> TYPE OF BUILDING OR USE SERVED <br /> 1 or 2 Family Number of Bedrooms: i` ❑ Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> X New System Cl 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 /> X 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 7.s U 1 t_-- <br /> Lift Pump Tank/Siphon Chamber <br /> Holding Tank capacity <br /> Manufacturer: <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 /> Si/G) w O a1 Private ❑ 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 (Print): Signature: MP/MPRSW No.: Phone Number: <br /> t,t- • C.c./ l <br /> 1_ /4:.// c,1S / r GC 1 �)g.,t,c-e'er. -�>~ S/Vi ',7;4__ (G-'-5 4— -74_<-/ y 7 <br /> Plumber's Yddress: / Name of Designer: <br /> no <br /> '/ / 3 '-.)/4 i /4 / --`) r't+ n:d--P 1, - ')-El Po I <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signature of Issuing Agent: Fee: Date: ❑ Disapproved <br /> rI Owner Given Initial <br /> [_ /�' -�y <br /> / ��i�i 1.1:c 06QyyL/ d Approved gdverse Determination <br /> R9,1/1/Lea <br /> n for Disapproval: 7 /// L <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 />