Laserfiche WebLink
APPLICATION FOR SANITARY PERMIT <br /> DILHR 6Urn64 COUNTY <br /> o¢Bmtmem oc (PLB 67) <br /> UNIFORM SA TARY PERMIT # <br /> � TpUSTAV,LFBOR6MVmnn REliiTlOnS _ <br /> —Attach complete plans in accord with s. H 63.05,Wis. Adm. Code for the system, on paper not less than 8%x 71 inches in size. <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> PROPERTY OWNER IftAILING ADDRESS <br /> M k'e kuS �- 1 01172Gt&, it'! WcS S'yflya <br /> PROPERTY�LLO..CIAITION c� CITY: <br /> /4�1/4, SZ ► , T3 ( N, RI W VWAGF: .fY( LGLL <br /> LOT NUMBER BLOCK NUMBER I SUBDIVISION NAMEARES OA LAKE OR LANDMARK STATE PLAN I.D. NUMBER <br /> ECC )401- ,e IHJIP- <br /> TYPE OF BUILDING OR USE SERVED <br /> kf or 2 Family Number of Bedrooms: T-1 Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> Ni—New System ❑ Tank Replacement ❑ Repair <br /> ❑ Replacement Soil Absorption System ❑ Revision ❑ Privy <br /> ❑ Alternate System ❑ Reconnection ❑ Petition for Modification <br /> IF �TcH,IS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. <br /> Lir Seepage Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holdiny 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 QQ l <br /> Lift Pump Tank/Siphon Chamber <br /> Holding Tank capacity <br /> Manufacturer: O h " T NL <br /> IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure <br /> Total #of Prefab. Site <br /> Gallons Tanks Concrete Constructed Steel Fiberglass Plastic <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 (02.=) Private ❑ Joint ❑ Public <br /> I,the undersigned, hereby assume responsibility fo installation of the private sewage system shown on the attached plans. <br /> Name of Pumber (Prin ): Sign tures MP/MPRSW No.: Phone Number: <br /> e(S o-eF r P S-7SY (71V Y6 -94 <br /> PI tier's Address: Name of D signer: <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signature of Issuing Agent: Fee: Date: <br /> C-15 <br /> ❑ Disapproved <br /> O 'A ff p� 5 Q_ i) _�s ❑ Owner Given Initial <br /> ./�0 / 7 Approved Adverse Determination <br /> ason for Disapproval: F' <br /> Alternate coursels)of Action Available: <br /> DILHR-SBD-6396 (R.5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner,Plumber <br />