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Wisconsin . APPLICATION FOR SANITARY PERMITle,, <br /> DILHR (PLB 67) COUNTY <br /> minOEPRRTTT1EnT OF UNIFORM SANITARY PER IT# <br /> MOMIMIM InOUSTRV,LRBOR S Human RELPT ions <br /> y3' 7v�� (/1; y6 <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 /> PROPERTYRO O NER / 7 MAILING ADDRESS ( � ( (�C� j <br /> PRO ERt'iTY LOCATION Q` (e TfCITY: INPk t- c "" t`-' J ` " ` 3 <br /> // VILLAG_F: /� cd/ <br /> 3 111/41&U�1/4, S (-, T3?UBDIVISN <br /> N, R l - ) W (1_ oF� / <br /> LOT NUMBER 'BLOCK NUMBER NAME S OAD)LAKE OR LANDMARK STATE PLAN I.D. NUMBER <br /> foe( eilse Rol <br /> TYPE OF BUILDING OR USE SERVED <br /> 1 or 2 Family Number of Bedrooms: 3 ❑ Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> , ' New System ❑ Tank Replacement ❑ Repair <br /> Ei Replacement Soil Absorption System ❑ Revision ❑ Privy <br /> Alternate System ❑ Reconnection ❑ Petition for Modification <br /> IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. <br /> Xi Seepage Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holding Tank <br /> riii 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 /Oo 7 / x <br /> Lift Pump Tank/Siphon Chamber <br /> Holding Tank capacity <br /> Manufacturer: 10 eSer CePIcre-k9 Pebb `I/UC— <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 /> D -.)- i /S ‘36 K Private Li Joint ❑ Public <br /> I,the undersigned, hereby assume responsibility for i tallation of the private sewage system shown on the attached plans. <br /> Name of Plumber (Pr'nt Signal re: MP/MPRSW No.: Phone Number: <br /> Plumber's Addre s: r Name f D sign r: <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signature of a,mwIssuing Agent: Fee: Date: El Disapproved <br /> /_ �p i L"• y„re,/ Approved Li Owner Given Initial <br /> ./' <br /> !� Q Adverse Determination <br /> eason for Disapproval: /CJ <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 />