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APPLICATION FOR SANITARY PERMIT <br /> l �' MS <br /> COUNTY� DILHR (PLB 67) <br /> UNIFORM SANITARY PERMIT# <br /> M or:rvawrmen eo�c <br /> nousrwY,rw swumwn wecwnans <br /> —Attach complete plans in accord with s. H 63.05,Wis. Adm. Code for the system, on paper not less than 8'/zx 11 inches in size. <br /> —See reverse side for instructions fo completing this application. PLEASE PRINT <br /> PROPERTY <br /> MAIING ADDRESS <br /> DI ),rrseTid Z,* " jW C o . 4 d C S 7' <br /> PROPERTY LOCATION CITY: <br /> SI e QfrL4w <br /> !CW � V <br /> , T QN, R � � (orlW OWN OF: <br /> LOT Nk1MBER BLOCK NUMBER SQUB IVISION NgME r 4(j f r r `E O LA�MARK� STATE PLAN I.O. NUMBER <br /> TYPEEf OF BUILDINGOR USE SERVED <br /> 73 <br /> i/ J /t /F)- <br /> 73 1 or 2 Family Number of Bedrooms. ❑ Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> [4 New System ❑ Tank Replacement ❑ Repair <br /> ❑ Replacement Soil Absorption System ❑ Revision ❑ Privy <br /> J Alternate System ❑ Reconnection ❑ Petition for Modification <br /> IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. <br /> M Seepage Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holding Tank <br /> J 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 So <br /> Lift Pump Tank/Siphon Chamber <br /> Holding Tank capacity <br /> Manufacturer: C. <br /> IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure <br /> Total <br /> to <br /> Prefab. Site Steel Fiberglass Plastic <br /> Gallons Tanks Concrete Constructed <br /> Septic Tank Capacity <br /> Lift Pump/Siphon Chamber <br /> Manufacturer: <br /> PERCOLATION RATEABSORPTION AREA ABSORPTION AREA WATER SUPPLY: <br /> (Minutes per inchl: REQUIRED (Square Feet l: PROtP'OSED (Square Feet): <br /> / O T 3 Private ❑ Joint ❑ Public <br /> I,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Na a of P/lumbgr (Pr, I. L Sig t re: MP/MPRSW No.: Phone Number: <br /> oC6 trft Ilt 5 11L <br /> C 9 W-F / <br /> Plumber's Address Name Desi nes: � <br /> .�L,d-ate. w,� • s- v e� <br /> COUNTY/DEPARTMENT USE ONLY <br /> Sign re of Iss g Agent: Fee: �� r <br /> a� �kJ_7�isappred <br /> ❑ Owner Given Initial <br /> Approved Adverse Determination <br /> 716n for Disapproval <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 />