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' APPLICATION FOR SANITARY PERMIT <br /> 1 77 ILHR COUNTY <br /> Z:: <br /> (PLB 67) UNIFORM SANITARY PERMIT # <br /> ainninniniv,cwoowswumwn wEcwnons 79 6_<1 <br /> —Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8%x 11 inches in size. .J <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> PROPERTY OWNER MAILING ADDRESS /VEW 3R 1 H 7-6 . <br /> 6OG `�T Y-4 CXJ <br /> PROPERTY LOCATION CITY: <br /> 1/4 #01/4, S 1'� , T3 , N, R E (or W VILLAGE: <br /> TOWN OF: — u;-l< - <br /> LOT NUMBER BLOCK NUMBER ISUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER <br /> /_A- UIrL 0 Ar G) 5 GC <br /> TYPE OF BUILDING OR USE SERVED <br /> �611 or 2 Family Number of Bedrooms. a ❑ Public (Specify): 71 <br /> THIS PERMIT IS FOR A: <br /> >�NevvSystem 5c=}Dfe ❑ Tank Replacement ❑ Repair <br /> Ll 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 _j IS rlk 6, ❑ Seepage Trench ❑ Seepage Pit ❑ Holding Tank <br /> ❑ System-In-Fill v ��? ❑ In-Ground Pressure ❑ Vault Privy ❑ Pit Privy( / <br /> ❑ Existing, For Which A Previous Permit Is On File, Permit # 5 1`7 ys $)ssued —'.Z <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 <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 <br /> Gallons Tanks Concrete Constructed Steel Fiberglass Plastic <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 /> Private LJJoint Ll 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): Sig ure: MP/MPRSW No.: Phone Number: <br /> Q 3cD7.;)- (7/J—) 2yy_3ao <br /> Plumber's Address: �y�! IName of Designer: <br /> /3t / <br /> - c/7 U ,1 J V—,,, <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signature of Issuing Agent: Fee: Date: ❑ Disapproved <br /> /{ <br /> Owner Given Initial <br /> Approved <br /> Adverse Determination <br /> ason for Disapproval: <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 />