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DI!THR <br /> APPLICATION PERMIT���� ��� UNIFORM SANITARY PERMIT# <br /> DUSTRY,LRBOR&HUMRn RELRTIOnS 5C170 (//3o ) <br /> —Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'/2x 11 inches in size. <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> PROPERTY OWNER MAILING ADDRESS 56 / ileco1 y /1i/L 0 <br /> 41A4u;N Sam Pb"IA /+i,'.vN 5ii&s" <br /> PROPERTY LOCATION Gov't •/ 7 <br /> And 1/4a! 1/4, S as , T3 , N, R /yE-for& Tiw oF: dFli1& <br /> LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE,OR LANDMARK STATE PLAN I.D. NUMBER <br /> 4/ emsymAi 'Ake <br /> TYPE OF BUILDING OR USE SERVED <br /> Er 2 Family Number of Bedrooms: LI Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> New System ❑ Tarok 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 /> page Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holding Tank <br /> Eli 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 0° / <br /> Lift Pump Tank/Siphon Chamber <br /> Holding Tank capacity <br /> Manufacturer: ai5`TQ.,7 PRf- CAS / <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 /> / <br /> l 'V/o VV Private ❑ Joint ❑ Public <br /> I,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Nappm��e of Plumber (Print): Si Cr ure: � <br /> "015/MPRSW No.: Phone Number:L/ <br /> Plumber's Address: Name of Designer: <br /> . /PT L syIex4 LAAZ, is 4-y(5'7! c`L Sc. ztrA/47c <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signature of Issuing Agent: Fee: Date: ❑ Disapproved <br /> �a <br /> Q . - .� A El Owner Given Initial <br /> Adverse Determination <br /> Q�yrZ�/ - LI +'�� � 'G Approved <br /> R son for Disapproval: �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 />