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F <br /> consin -, APPLICATION FOR SANITARY PERMIT p <br /> DILHR �(PLB 67) UNIFORM SANITARY PERMIT # <br /> iUSTRV,LRBOR 6 HUTRn RELRTIOns O' �^/ (//� /F 1 - <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 inch..ees in size. f(J <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> PROPERTY OWNER MAILING ADDRESS <br /> PROPERTY CITY: <br /> J­N1ERTY LOCATION �- <br /> W 1/4 1J�,,J/4, S , T ;� N, R "E-far) W TO GF: W do CL i 0 C r <br /> LOT NUMBER I BLOCK NUMBER SUBDIVISION NAME NE RES D OA L1K E OR LANDMARK STATE PLAN I.D. NUMBER <br /> 4 <br /> TYPE OF BUILDING OR USE SERVED <br /> X 1 or 2 Family Number of Bedrooms. ❑ Public (Specify): <br /> THIS PERMIT IS FOR A: <br /> X 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 Fiberglass Plastic <br /> Gallons Tanks Concrete Constructed <br /> Septic Tank Capacity 010If> <br /> Lift Pump Tank/Siphon Chamber <br /> Holding Tank capacity <br /> Manufacturer: t " �t oA,,,C cr6 <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 nstallation of the private sewage system shown on the attached plans. <br /> Name of Plumber (Pri t): Sign a re: MP/MPRSW No.: Phone Number: <br /> P umber's Address: Name of Designer <br /> eC � <br /> COUNTY/DEPARTMENT USE ONLY <br /> Sign ture of Issuing Agent: Fee: Date: ❑ Disapproved <br /> r/� j /`'/S( ❑ Owner Given Initial <br /> ZGo 7 ��1Approved Adverse Determination <br /> ason for Disapproval: t <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 />