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.7E.�= n�STR�, <br /> APPLICATION FOR SANITARY PERMIT <br /> ILHR COUNTY <br /> (PLB 67)TmenT ae UNIFORM SANIT RY PERM T# <br /> LREI 6MUTgn gELRT10n5 <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 /> P ER Y OWNER MAI4LING ADDRESS/ J/ 4h A <br /> I L.o to a1.0 4 of �c �10 ! A f <br /> PROPERTY LOCATION CITY: c� <br /> 1+,11/4 � W/4, S T O N, Rill@ (or) W V WN of <1 G O <br /> LOT NUMBER BLOCK fVS1MBER SUBDIV OIsj NAME NEAREST ROAD LAKE �SANDDM RIG � STATE PLAN I.D. NUMBER <br /> Ld <br /> TYPE OF BUILDIN/+G✓/O/RT1cUSE SERVED //-Tj K/,7,J A/ C GI/ <br /> IR9 1 or 2 Family Number of Bedrooms. ❑ Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> XNew System ❑ Tank Replacement ❑ Repair <br /> ❑ Replacement Soil Absorption System ❑ Revision ❑ Privy <br /> ❑ Alternate System ❑ Reconnection ❑ Petition for Modification <br /> IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. <br /> Xl 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 '] J16 <br /> Lift Pump Tank/Siphon Chamber <br /> Holding Tank capacity <br /> Manufacturer: ' L <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): PROISOPOSED (Square Feet): <br /> ro y a_ 2 Private ❑ Joint ❑ Public <br /> I,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Na a of P umber (Print): $i re: MP/MPRSW No.: Phone Number: <br /> 1r �;mako <br /> Plumber's dress' Nam of e 'gner: <br /> ( �J S- <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signature of Issuing Agent: Fee: Date: <br /> ���lll ❑ Disapproved <br /> I aj,5—da � ���� �/ ❑ Owner Given Initial <br /> / fP0 /o< Approved Adverse Determination <br /> ason for Disapproval: 17 Xr/ <br /> Alternate courses)of Action Available: <br /> DILHR-Se D-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner, Plumber <br />