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^_^ APPLICATION FOR SANITARY PERMIT <br /> DILHR <br /> 'L-��+-'S6i"1".�.� COUNTY <br /> (PLB 67) <br /> dRRRTmenT oc UNIFORM SANITARY PERMIT # <br /> E77 <br /> InOUSTRV.LRBOR6MUTRn RELRT1On5 j����� / )/ / /], /1L <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 MAILING ADDRESS <br /> to M9&,L-r- p4rr M~41 <br /> PROPERTY LOCATION CITY: <br /> VILLAGE: <br /> W 1/4-51/4, S Igo , T 3y N, R / r(or) W TOWN V <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 /> �hq 1 or 2 Family Number of Bedrooms: Tj Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> X 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 /> LXd 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 73Z <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 /> I S//O y10Private ❑ 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): Signature: MP/MPRSW No.: Phone Number: <br /> ,r caaf/t <br /> Plumber's ddress: Name of Designer: <br /> / 3 S' oi ,'1A, Sl S v s %! r12 <br /> COUNTY/DEPARTMENT USE ONLY <br /> Sign a of Issuin ge t Fee: ❑ Disapproved <br /> ElOwner Given Initial <br /> Date: <br /> S✓ '/J—g- XApproved Adverse Determination <br /> ason for Disapproval: <br /> Alternate coursels)of Action Available: <br /> DI LHR-SBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner,Plumber <br />