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""S`O"5I'l APPLICATION FOR SANITARY PERMIT <br /> � DILHR �` COUNTY <br /> (PLB 67)OEPRRTTTIEI'1T OF UNIFORM SANITARY PERMIT# <br /> � <br /> - InOUSTRV,LRBOR 6HUTRn RELRTIOnS <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 /> P PE TY OWNER f MAILING ADDRESS t <br /> ilen <br /> PROPERTY LOCATION CITY: _ <br /> SF1/4S L'1/4, S 3 , T ION, R I �V(or) W VI WN OF jr, C_ c' r <br /> LOT MBER IBLOCKNOMBER 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 /> El Replacement Soil Absorption System ❑ Revision ❑ Privy <br /> EJ 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 /> El 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 , <br /> Lift Pump Tank/Siphon Chamber <br /> Holding Tank capacity <br /> Manufacturer: tC <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 /> `F' ''1// 0 7 � Q_ [X Private ❑ Joint ❑ Public <br /> I,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Narpg of PI mbe;(Print): Sig T MP/MPRSW No.: Phone Number: <br /> Plumber's dress• INpof Designer: 'L <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signature of Issuing Age t: Fee: Date: <br /> ❑ Disapproved <br /> f / ! `��' _� ❑ Owner Given Initial <br /> � b <br /> Approved Adverse Determination <br /> ason for isapproval: <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 />