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� D�^ APPLICATION FOR SANITARY PERMIT <br /> I LHR p FOR COUNTY <br /> oEPRRTirIEin aF (PLO 67, UNIFORM SANITARY PERMIT# <br /> eat Inou5TRV.LR80R&H MRr1MLRTIonS <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. <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> PROPERTY OWNER MA.LLIWG ADDRESS / <br /> vt `f wra Gli 11-11101 S b 4 r Ld S Y r/ <br /> PR ER�II,®CATIO CITY: - <br /> •v 1/4 a. 1/4, S ;IS' , Ty,0N, R /s- 4 <br /> WN <br /> (or) OOF: To f to <br /> LOT NUMBER I BLOCK NUMBER SUBDIVISION NAMENEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER 1*141 -it tr <br /> TYPE OF BUILDING OR USE SERVED <br /> X 1 or 2 Family Number of Bedrooms: 3 ❑ Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> W 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 /> 9 Seepage Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holding Tank <br /> El System-In-FiII ❑ 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 <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 AREAABSORPTION AREA WATER SUPPLY: <br /> (Minutes per inch): REQUIRED (Square Feet): PROPOSEVD (Square Feet): <br /> 3 & /S' // S/ d I OM Private ❑ Joint ❑ Public <br /> I,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Na of Plumber (Pr t): Si nr MP/MPRSW No.: Phone Number: <br /> o ,e Ilk e e I�t i• 9 pd+�-U.�s./� d >0Tj 71r) <br /> Plumber's Addr F I Nam of Designer: <br /> � 1 . S`y8Q <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signature of Issuing Agent: Fee: Date: ❑ Disapproved <br /> ❑ Owner Given Initial <br /> Approved Adverse Determination <br /> eason for Disapproval: <br /> Alternate courses)of Action Available: <br /> DI LHR-SBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner, Plumber <br />