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wmconsin APPLICATION FOR SANITARY PERMIT <br /> DILHR COUNTY <br /> (PLB 67) UNIFORM SANITARY PERMIT# <br /> E(�� <br /> TTEn7 OF <br /> inouSTRVLRBOInOLlS , FI6 MUR1gn RELiiTM]I'IS <br /> —Attach complete plans in accord with s. H 63.05,Wis.Adm. Code for the system, on paper not less than 8Y2x 11 inches in size. <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> PROPERTYTNER MAILING ADDRESS L <br /> Dr 3 / 0 S 0 9 A o je r-L jerc ltefl Gr- <br /> PROPER LOCATION IeK CITY: —�- <br /> Scr' 1/4 SU /A S A0 , Ty 9 N, R. (or) W TOWN S C d � / <br /> LOT NrMBER BLOCK NI�MBER SUBDIVISIQN NAME AREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER <br /> N Ill` Ir\`\ U V �'f L <br /> TYPE OF BUILDING OR USE SERVED <br /> Ld 1 or 2 Family Number of Bedrooms: 3 ❑ Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> C9 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 /> ® 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 Fiherglass 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 WATER SUPPLY: <br /> (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): <br /> la 61-5—-5— 6 1f F I X Private ❑ Joint ❑ Public <br /> I,the undersigned,hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> N e of P umber (Print); Sign MP/MPRSW No.: Phone Number: <br /> o e s o to U 3 o.� (lis)866 is�'1 <br /> Plumber's A dress: N of Designer: ` <br /> w <br /> IS-4rIF 73 <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signature of Issuing Agent: Fee: Date: ❑ Disapproved <br /> 'l <br /> %A /D % /_ -; El Owner Given Initial <br /> /D Approved Adverse Determination <br /> R6dson for Disapproval: <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 />