Laserfiche WebLink
wl5co-5,n APPLICATION FOR SANITARY PERMIT <br /> ® I LHR X�� COUNTY <br /> — OEPRRT1TEnT OF (��� ��) UNIFORM SANITARY PER MI. # <br /> — InOUSTRV,LRBOR&HUITRn RELRTIOnS f,2 71J�— (/ 3-�7 <br /> —Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'/zx 11 inches i`nsize. <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> PROPERTY OWNER MA I G ADDRESS <br /> 4 k -- " Pt Oren � i. <br /> PROPERTY LOCATION CITY: <br /> E 1/4PF-1/4, S ,S TY� N, R )S` E' (or) W VI WN OF• J rt �C,I` <br /> LOT NUMBER I BLOCK NUMBER SUBDIVISION NAME EAT ROAD, LAKE OR LANDMARKSTA <br /> � TEPLAN I.D. NUMBER <br /> 'a f/ 'p R /) <br /> TYPE OF BUILDING OR USE SERVED <br /> 1 or 2 Family Number of Bedrooms: ❑ Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> N New System ❑ Tank Replacement ❑ Repair <br /> El Replacement Soil Absorption System ❑ Revision ❑ Privy <br /> ❑ Alternate System ❑ Reconnection ❑ Petition for Modification <br /> IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. <br /> bF 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 S t_ <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): PROPOSED (Square Feet): <br /> 'Private ❑ Joint ❑ Public <br /> I,the undersigned, hereby assume responsibility for installation of the private sews e system shown on the attached plans. <br /> Nr of lumber (Prin S nature MP/MPRSW No.: Phone Number: <br /> Plumber's Addr ss: A Name of Desi ner: <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signature of Issuing Agent: Fee: Date: ❑ Disapproved <br /> i $ % <br /> � A roved ❑ Owner Given Initial <br /> QiYh�1 pp Adverse Determination <br /> eason for Disapproval: J <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 />