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nEoPuMsirrRT�, APPLICATION FOR SANITARY PERMIT <br /> E77 , COUNTYILHR (nLB 67) <br /> Enr OF UNIFORM SANITARY PERMIT # <br /> cweoR s wumwnw LRnons 7V 73_�' 7) <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. <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> PRO ERTY OWNER MAILING ADDRESS p r <br /> ✓` 4C `e 8NrrS c /D 77 U. <br /> PROPERTY LOCATION `` CITY: <br /> �W 1/4S€1/4, S / 7 , TYQN, R l� (or) W OWN OF /i D /lv <br /> LOT NUMBER BLOCK N MBER SUBDIVISION NAME AREST.$OAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER <br /> ,v �owti n d <br /> TYPE OF BUILDING OR USE SERVED <br /> )`1 or 2 Family Number of Bedrooms. Tj Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> X New System ❑ Tank Replacement ❑ Repair <br /> EJ 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 <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 r <br /> T <br /> 7 <br /> tP ER SUPPLY: <br /> (Minutes per inch): REQUIRED (Square Feet): PROPOS/ p <br /> E D (Square Feet): <br /> 7 r E 0 ® Private ❑ Joint ❑ Public <br /> I,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Na of PI ber (print):,{... ,�L Sign ui a MP/MPRSW No.: Phone Number: <br /> Plumber's Aqdress <br /> �` _ �j f/ Name of Desig er: <br /> ii <br /> COUNTY/DEPARTMENT USE ONLY <br /> Sign a of Issui Age Fee: Date: <br /> o r ❑ Disapproved <br /> / // ❑ Owner Given Initial <br /> /CO Approved Adverse Determination <br /> ason for Disapproval: <br /> Alternate courses)of Action Available: <br /> DILHR-SBD-6396 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner, Plumber <br />