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ECD <br /> wlsconsln APPLICATION FOR SANITARY PERMIT(PLB 67) <br /> DILHR � COUNTY <br /> OEPRRTTT1EnT OF UNIFORM SANITARY PER T# <br /> InOUSTRV,LRBOR 6 HUMRn RELRTIOr15 <br /> —Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'hx 11 inches in size. <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> PROPERTY OWNER MAILING ADDRESS <br /> 'T� <br /> ` /3' 3 w <br /> PROPERTY LOCATION CITY: <br /> ` VILLAGE: <br /> w 1/4 ): 1/4, S i 0 , T� , N, R q Q (or) W TOWN OF: <br /> LOT NUMBER I BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER <br /> TYPE OF BUILDING OR USE SERVED <br /> X 1 or 2 Family Number of Bedrooms. ❑ Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> ❑�"(�' New System ❑ Tank Replacement ❑ Repair <br /> LGJ Replacement Soil Absorption System ❑ Revision ❑ Privy <br /> Ll Alternate System ❑ Reconnection ❑ Petition for Modification <br /> IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. <br /> ❑ Seepage Bed IX Seepage Trench ❑ Seepage Pit ❑ Holding Tank <br /> Ej 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 -7 p <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 /> 1 /G 5- 16 5"- EY Private ❑ 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 /> Plumber's Address: Name of Designer: <br /> �1/3 .S M/ c o -C t— L J 7 <br /> S o" S'v <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signature of Issuing Agent: Fee: Date: <br /> ❑ Disapproved <br /> Q7/ °` q p ❑ Owner Given Initial <br /> Approved Adverse Determination <br /> ason for Disapproval: C� <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 />