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°^^�^ APPLICATION FOR SANITARY PERMIT .(��'�� <br /> ( DI�LHR ��rh` BOUNTY <br /> or'wwwnnen, (PLB 67) <br /> UNIFORM SANITARY PERMIT # <br /> inousrw�,iweowswumwnweuwrions 7s17y7 (H( / is- <br /> EZ <br /> S <br /> —Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'/sx 11 inches in size. T <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> PROPERTY OWNER MAILING ADDRESS <br /> F'd wa I,d u 1e�. .1 Box a8 1. ek!S t Cats S v�I3 <br /> PROPERTY LOCATION // CITY: <br /> S C 1/4SW7/4, SAO , T39, N, RA0-E-(Dr Q GF: kn Pfh0/7 <br /> LOT NUMBER I BLOCK NUMBER SUBDIVISION NAME NEARE RO , LAKE OR LANDMARK STATE PLAN I.D. NUMBER <br /> COG il- "b" <br /> TYPE OF BUILDING OR USE SERVED <br /> 1 or 2 Family Number of Bedrooms. a Tj 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 /> 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 S•O If <br /> Lift Pump Tank/Siphon Chamber <br /> Holding Tank capacity <br /> Manufacturer: F _f%,t c r-e Wi <br /> "U <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 /> y.,l 0 1 Nr Private ❑ Joint ❑ Public <br /> I,the undersigned, hereby assume responsibility for in tallation of the private sewage system shown on the attached plans. <br /> Name of Plumber (Print): Signa e: MP/MPRSW No.: Phone Number: <br /> lS <br /> Lo X0 s-7$ 7 .570 � <br /> Plu ber's Address: --T—Nam-e0 <br /> f esigner <br /> +• � �S4-er WcS X1 PS e-to - r <br /> COUNTY/DEPARTMENT USE ONLY <br /> Sign ture of Issuing Agent: Fee: Date: Disapproved <br /> ❑ <br /> �o ❑ Owner Given I <br /> nitial <br /> �!/ o ,Approved Adverse Determination <br /> eason for Disapproval: K <br /> 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 />