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P.mli wlstonsin APPLICATION FOR SANITARY PERMIT <br /> DILHR lL COUNTY <br /> (PLB 67) UNIFORM SANITARY PERMIT# <br /> MMINIMIIMMIN OEPRRTTT1EOT OF <br /> InOUST RV,LRBOR6HUTRnRELPTIOn5 // ya) <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 /> 11i Ales O I eN Ti S 7-;. ' Ri -57ro0N'e rr w:_'. -;-`i to I <br /> PROPERTY LOCATION CITY: <br /> VILLAGE: <br /> 4401/4SO 1/4, S 34, , T cN, RI'/ r (or) W TUN OF: �'C©� <br /> LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER <br /> TYPE OF BUILDING OR USE SERVED <br /> A 1 or 2 Family Number of Bedrooms: of ❑ Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> A 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 /> X Seepaye Bed ❑ Seepage Trench U Seepage Pit ❑ Holding Tank <br /> LI 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 75 V / L- <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 /> / 41/0 y/0 A Private Li 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): Si gnat re: MP/MPRSW No.: Phone Number: <br /> Ca ,/ L4-) -PP4 U I s a N -�-7 w Q -x' 4/L// �- �s.r�- a Li?7 <br /> Plumber's ddress: Name of Designer: <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signature of Issuing Agent: Fee: Date: ❑ Disapproved <br /> ����/ / �� �J / i % )j_' ‘ L� OwnerdverGiven Initial <br /> T (p(/ /-"t XApproved Adverse Determination <br /> eason for Disapproval: <br /> Alternate coursels)of Action Available: <br /> DILHR-SBD-6398 (R.5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner,Plumber <br />