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MMOMMAM Wisconsin ' 1. - APPLICATION FOR SANITARY PERMIT <br /> �1 D' � � � U �`E� _COUNTY <br /> u (PLB 67) UNIFORM SANITARY PERMIT# <br /> OEPRRTTT I EnT OF <br /> InOUSTRV,LRBOR 6 HUMRn RELRTIOnS <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 in size. <br /> —See reverse side for instructions for completing this application. PLEASE PRINT <br /> PR P,ei Y�OWNEI� > � MAILING ADDRESS <br /> -P171Alcl= Sa y��j k t! <br /> P OPERTY LOCATION CITY: r a '�` <br /> �114�1f�14, S3S, f5 , N, R /��E-for VIL N OF: � `- <br /> LOT NUMBER BLOCK NUMBER SUBDIVISION NAME ST ROAD, AKE R 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 /> ❑ 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 /> XSeepage Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holding Tank <br /> EJ System-In-Fill ❑ In-Ground Pressure ❑ Vault Privy G�❑ Pit Privy <br /> Existing, For Which A Previous Permit Is On File, Permit # I S&O (616�) issued l "-1�;L -7-7 / <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 /> Eyt S fe n I 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 /> �� �C31-0 Private ❑ Joint ❑ Public <br /> I,the undersigned, hereby assume responsibility fo installation of he private sewage system shown on the attached plans. <br /> Name of Plumber (Pri tl Sign t e: MP/MPRSW No.: Phone Number: <br /> -2 F- �� P 5 7f (71 <br /> Plu er's Address: � Name of Designey. <br /> COUNTY/DEPARTMENT USE ONLY <br /> Sign ture of Issuing Agent: Fee: Date: ❑ Disapproved <br /> dI/Q,� � ❑ Owner Given Initial <br /> L4LZW�� 1✓/& (o Approved Adverse Determination <br /> Reason for Disapproval: X'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 />