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5OOA5^ APPLICATION FOR SANITARY PERMIT <br /> ( -DILHR COUNTY <br /> (PLB 67) <br /> oerx,wTmenr or UNIFORM SANT ARY PERMIT # <br /> InOLISTRV LR90R6MU,MngELPTIpnS ��/�' / <br /> r <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 �f <br /> �c sGh /` Orr SO STorr- /lU Eq,, e 461r'V wl <br /> PROPERTY LOCATION CITY: <br /> W 114SE 1/4, S A , T YON, R & 8 (or) W OWN OF 0 9 LE n l <br /> LOT NUXER I BLOCK NUMBER SUBDIVISION NAME SOT ROA AI E OR LANDMARK STATE PLAN I.D. NUMBER Al k- AlAr I <br /> O/ <br /> TYPE OF BUILDING OR USE SERVED <br /> 1 or 2 Family Number of Bedrooms. ❑ Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> ❑ New System XTank Replacement ❑ Repair <br /> K 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 0 x <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 Site <br /> Septic Tank Capacity <br /> Lift Pump/Siphon Chamber <br /> Manufacturer: <br /> PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: <br /> (Minutes per in REQUIRED ISquare Feetl: PROPOSED (Square Feet): <br /> joQ 5i3 a— XF 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 lumber (Print): Sig e: , MP/MPRSW No.: Phone Number: <br /> 0 �proc d �fnS (T 0 05' )A-)Sk, y/S <br /> Plumber's Address: I Na of Designer: <br /> s 3 <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signature of Issuing Agent: / Fee:�j Date: r� ❑ Disapproved <br /> Approved <br /> Ll Owner Given Initial <br /> Adverse Determination <br /> ason for Disapproval: 17 is j <br /> Alternate coursels)of Action Available: <br /> DILHR-SBD 6398 (R.5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner,Plumber <br />