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,APPLICATION FOR SANITARY PERMIT <br /> � D I L H R (PLB 67) ����� COUNTY <br /> U IFORM SANITARY PE MIT # <br /> a�oEPf%iTR1EnT OF /I <br /> OVSTRV LRBOR6MLJTRfIRELRT1IX15 // <br /> —Attach complete plans in accord with s. H 63.05,Wis. Adm. Code for the system, on paper not less than 8Y x 11 inches in size. (o <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> PROPERTY OWNER MAILING A/p DRESS <br /> IL Tq ! Qtt �J 11 f WI <br /> PROPERTY LOCATION -e T., <br /> VittA13E: <br /> SE 1/4 /4, S 13 , o, N, R/S I? (or) W TOWN OF: <br /> LOT NUMBERBLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER <br /> *A t of <br /> TYPE OF BUILDING OR USE SERVED <br /> Y"° 1 or 2 Family Number of Bedrooms: ❑ Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> ❑ New System ❑ Tank Replacement ❑ Repair <br /> �1 Replacement Soil Absorption System ❑ Revision ❑ Privy <br /> ❑ Alternate System ❑ Reconnection ❑ Petition for Modification <br /> IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. <br /> X 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 ...-il 3' /f n ID V <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 #ofPrefab. 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): PR/OPOSE`D/(,Square Feetl: <br /> J 6 /-y- (10 Y Private ❑ Joint ❑ Public <br /> I,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> N of P umber (Print_): Si re: MP/MPRSW No.: Phone Number: <br /> Plumber's A dress: Name of Designer: <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signature of Issuing Agent: Fee: Date: ❑ Disapproved <br /> /r - �n ❑ Owner Given Initial <br /> y Approved Adverse Determination <br /> eason for Disapproval: C/ <br /> Alternate courses)of Action Available: <br /> DILHR SBD-6398 (R.5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner,Plumber <br />