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F-,5con5," APPLICATION FOR SANITARY PERMIT /1DILHR V/�/'��e��� COUNTY <br /> (PLB 67) UNIFORM SANITARY PERM T#FUSTgV,LRBOR 6 MUTRn RELPTIOnS <br /> 7,�F l/3S/ <br /> —Attach complete plans in accord with s. H 63.05,Wis. Adm. Code for the system, on paper not less than 8'/2x 11 inches in size. <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> PROPEF�T�OWNER � MAILING ADDRESS <br /> -: — JJ1I Ty 14 ;74 ,- <br /> PROPERTY LOCATION CITY: <br /> 1/4,Sk41/4, S T914N, RAP & (or) W ' WNof � �" y A d <br /> LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER <br /> TYPE OF BUILDING OR USE SERVED <br /> 1 or 2 Family Number of Bedrooms: ❑ 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 /> 1)4 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 ,j c /� <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 i 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 /> �— y / 0 T -� �, [51 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 Plumber (Print): S' re: MP/MPRSW No.: Phone Number: <br /> Plumber's A ress !/ Na of Des <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signature of Issuing Agent: Fee: Date: ❑ Disapproved <br /> ` of ❑ Owner Given Initial <br /> �il_for <br /> Approved Adverse Determination <br /> Disapproval: r� <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 />