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WISCOnSInAPPLICATION FOR SANITARY PERMIT <br /> DILHR6t�� P"-e-atE COUNTY <br /> (PLB 67) UNIFORM SANITARY PERMIT# <br /> IIIIIIMI OEPRRTTEAT OF <br /> INEMONI IfOUSTRY.LABOR&HUR1Rn RELRTIOnS <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 /WI, <br /> PR ERTY OW ER MAILING ADDRESS, e <br /> 1 I).19 �� /4W_ `'vy\ ; 1 t'r c! :1 - ��o / ! od[ - st'- tv `F;. .'i 1 ,/ ‹, L <br /> PROPERTY LOCATION / CITY: <br /> 1/4 74i:-.-1/4, � <br /> 1/4, S .-3.'s.--, T ft,!N, R i ' �V - <br /> (or) W t OwLAG.N OFy: O 9fri u i <br /> LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD,''ttAKE OR LANDMARK STATE PLAN I.D. NUMBER <br /> Al A- iU' A WA 0ti is Ceti, K'd <br /> TYPE OF BUILDING OR USE SERVED <br /> X1 or 2 Family Number of Bedrooms: U Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> LNew System ❑ Tank Replacement ❑ Repair <br /> ❑ Replacement Soil Absorption System ❑ Revision ❑ Privy <br /> ❑ Alternate System ❑ Reconnection ❑ Petition for Modification <br /> IF THIS ISA CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. <br /> X Seepage Bed ❑ Seepage Trench U 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 /> 1, <br /> Septic Tank Capacity ',j k) t <br /> X <br /> Lift Pump Tank/Siphon Chamber <br /> Holding Tank capacity <br /> Manufacturer: 'tile") <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 /> Li / 0 y 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 umber (Pri{�t): Sig9ate)re: .i 'r ., /MPRSW No.: Phone Number:y <br /> . t i !r- `[V__ `t\tie k1'G. I• /��' 'C4.e -� .j C` .t�`/ • (jf S) d t e t ,,I`'7 <br /> PI ber's AdcJress: ,2. Name of Designer: <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signature of Issuing Agent: Fee: <br /> �: Date: CI Disapproved <br /> ay ✓ yy4*,,,j tJ . c Approved El Owner Given Initial <br /> Adverse Determination ion <br /> eason for <br /> Disapproval: ,C J / \ <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 />