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SCD"51" APPLICATION FOR SANITARY PERMIT <br /> -COUNTY <br /> (PLB 67) <br /> UNIFORM SANT ARY PER IT # <br /> OEPRRTTEIIT OF <br /> - IIlOLJSTgV LRROq 6 MUTRrI RELRT10115 <br /> Uo6 7 /6�o <br /> —Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 81/,xii inches in size. <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> PR OPERTV OWNER T MAILING ADDRESS ,f <br /> t (rl.l CFTC r. P � -P Zo so S T 00a u < <br /> PROPERTY LOCATION T,y; <br /> S'W1/4 'ZLdi 4, S o7 , T QN, R /S'0 (or) W TOWN OF: T C LU <br /> LOT NUMBER BLOCK NUMBER SURDIVIS{ON NAME NEAREST;OSA D, UA EOR H DfIpAIi STATE PLAN I.D. NUMBER <br /> TYPE OF BUILDIN/G/"O/RATUSE SERVED <br /> 7( <br /> ^� N --6{ S l/ h/ <br /> 7( 1 or 2 Family Number of Bedrooms: O` J Public (Specify(: <br /> THIS PERMIT IS FOR A: <br /> EK New 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 /> K Seepage Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holding Tank <br /> J 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 <br /> Gallons Tanks Concrete Constructed Steel Fiberglass Plastic <br /> Septic Tank Capacity 7 ^ X' <br /> Lift Pump Tank/Siphon Chamber <br /> Holding Tank capacity <br /> Manufacturer: U1 C_ <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 Feetl: <br /> 7 � 0 3� eL 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): Sign MP/MPRSW No.: Phone Number: <br /> of X <br /> JV Plumber's A dress: <br /> N of Designer: <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signature of Issuing Agent: Fee: Date: ❑ Disapproved <br /> XApproved ❑ Owner Given Initial <br /> d ✓ W Adverse Determination <br /> reason for Disapproval: <br /> Alternate course(s)of Action Available: <br /> DI LH R-SED-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner, Plumber <br />